Going gray to white

Old age often creeps up on people, and those who have not seen their elderly relatives for some time may be shocked by the deterioration in their looks and physical and cognitive abilities. But sometimes a sudden event, such as a hip fracture or a stroke, shoots down active, vibrant individuals and makes them totally dependent on others.

In both cases, relatives and friends are confused about the symptoms, how to help and how much recovery to expect. Hebrew speakers among them will be grateful for a new book by Herzog Hospital geriatrician Dr. Efraim Jaul. Called Sipurim Shesipru Li Metupalei: Hitmodedut Ma’asit Im She’elot, Levatim Umatzavim Gufaniyim Begil Hahizdaknut (My Patients’ Stories: A Practical View on the Fears and Physical Conditions of Growing Old), the 268-page volume was published by Eshel, the Association for Planning and Development of Services for the Elderly in Israel. It joins a growing list of books, films and other Eshel publications meant to help educate and inform the rapidly aging public in Israel, where average life expectancy is moving into the ninth decade.

Jaul, director of the expanding psycho-geriatric hospital in Jerusalem’s Givat Shaul quarter, is director of its complex nursing department and has been with Herzog for 20 years. A graduate of the University of Rome and former director of an a prize-winning Clalit Health Services’ family medicine clinic in Jerusalem’s East Talpiot neighborhood, he has written several Hebrew-language volumes in his field, including The Geriatric Nursing Patient, The Mature Traveler’s Guide and publications on diagnosis and treatment of pressure sores and on enteral feeding of the elderly.

This latest book covers complicated issues such as what age-related changes can be expected and how can they be delayed or avoided; what tools measure functioning and why is this often more important than diagnosis of a disease; what periodic tests and examinations need to be performed and how conditions can be prevented at an advanced age; and the importance of nutrition and physical exercise.

“The aim of this book is to shed light on the physiological and pathological processes that occur in old age,” Jaul writes, adding that he hoped that after reading it, patients and their families and caregivers would regard aging as less threatening and easier to cope with. Throughout, the author illustrates his points with moving true stories about his own parents and the many elderly people he has treated.

He recommends that older people not think constantly of diseases but of potential stumbling blocks – such as weaker hearing or sight or stiff joints that usually accompany aging and can get in the way but can be dealt with. “Your rich life experience and wisdom will help you plan for it.

Don’t let it surprise you,” he writes.

He provides a list of practical ideas that make life easier, such as: Think ahead. Don’t climb on a chair or ladder to change a light bulb, clean a chandelier or take down a book as you did 40 years ago. Ask for help so you don’t lose your balance and fall. If you still drive, don’t do so at night, in bad weather or in unfamiliar territory. Don’t cross streets except at a crosswalk, and when you do, only on a green light. Don’t carry heavy baskets or packages in both hands so you’ll be able to protect your head if you encounter an obstacle. Always hold the bannister when on the stairs. Don’t sit on a low chair without a backrest so you won’t have difficulty getting up or fall backwards.

Build up relationships with relatives and friends so you have social support. Set goals and find significance for your life so you’ll have a good reason to get up in the morning.

A long list of natural changes in the body that occur as people age is presented over four pages. These include joints and bones; nerves, eyes, ears, touch, smell and taste; kidneys, cardiovascular system; digestion; respiratory function; skin, immune system and sexual function.

Jaul recalls when his mother had a stroke in 1995.

“When I entered her room, I saw her lying with her right hand lifeless and her mouth wide open. She was giving me a hollow look. I immediately diagnosed her with a stroke. That ended the trip to rediscover their roots [in Austria] that I took with my parents. I looked at her, and I couldn’t help her. She gazed at me with the desperate look of ‘Help me!’ She was then 72, an independent woman, energetic and young in spirit.”

She was hospitalized in a Vienna neurology department until she could be flown home. In Jerusalem, she improved, until the last day of her hospitalization, when she slipped in the corridor and broke her hip.

“She had surgery immediately,” Jaul recalled. “Her rehabilitation stopped. She had low moods. Her motivation disappeared, and she sank into depression.”

They took her home, in the hope she would improve.

“As a son and doctor, I felt great frustration and helplessness in the face of all her nursing problems, problems I treated well in others.”

His mother refused to get up and walk, wash or feed herself, and the geriatrician and his sister carried the burden. Pressure sores developed. At first, they didn’t know where to turn, despite his long experience.

Finally, they ordered home care from their health fund, and had a doctor, nurse, social worker, physiotherapist and occupational therapist come for treatment.

She had a turn for the better, her pain receded, and she became more motivated.

She lived in sheltered housing and was alert, walked with a cane, learned to play bridge, was active daily, learned to draw and wrote two books on her Holocaust experiences. She died 12 years after suffering her stroke.

Jaul’s father suffered for years from orthopedic problems due to erosion of his joints – the result of being shot in his right leg by an Arab sharpshooter in the War of Independence. But although he limped for the rest of his life and his weight was carried by his left side, causing the joint problems, he enjoyed a very active life. When he reached the age of 82, he developed cardiac insufficiency, three clogged coronary arteries and a serious heart valve problem, and a specialist recommended open-heart surgery.

Shifting to the role of a son, Jaul was leery of a seven-hour operation, fearing it could affect his father’s cognitive functioning. The attending physician was surprised by their decision – which turned out to be the right one, because Jaul’s father lived to the ripe old age of 88.

“For me, as a son and a doctor, every year that my father lived and functioned physically and mentally with a good quality of life showed we were right not to approve the surgery,” he writes in his chapter on operations.

SOME OF Jaul’s middle-aged and elderly patients insisted that there was no use changing their lifestyle because “genetics determines everything.” A Jerusalemite carpenter named Menashe – a tall, hefty and broad-shouldered smoker – who came to consult him about his wife and parents hadn’t come to the clinic about himself, even though he was nearing 60.

Jaul suggested tests for early diagnosis of various conditions.

The doctor advised him to quit smoking, lose weight and reduce his consumption of sugar and white flour.

“At first, he turned me down, saying he knew centenarians who never needed to see a doctor ‘because they had good genes.’” But he agreed to take the tests and was shocked to learn that he had high cholesterol, triglyceride and sugar levels, and when Jaul took his blood pressure, it too was too high. But he ignored the data and told everyone he was fine.

“Welcome to the club,” the doctor said, and finally persuaded him to prevent disease by walking, changing his diet and giving up cigarettes.

The book includes helpful charts that list tests and vaccinations that the middle aged and elderly need to undergo and when to have them. One chapter is devoted to medications, which are commonly abused by old people. Either they take too many – because their various specialists have not made sure that the drugs don’t clash or have become unnecessary – or they don’t take those their doctors have prescribed.

“I never take these pills,” Elizabeth said, referring to little yellow ones she brought in a bag. Jaul identified them as being to reduce blood pressure. Elizabeth came with complaints about being weak and unstable when walking, which made her fear falling. When asked why she avoided taking them even though that could be responsible for her symptoms, the patient said: “I really value my doctor, but I know what’s good for my body.”

Absorption in the stomach and diffusion of drugs in the bloodstream change as people age. Jaul also explains the connection between drugs, food and herbal preparations, as well as when generic drugs can be taken safely.

Preparing for and coping with retirement and with the death of a spouse fill up other chapters, as do elder abuse, suiting the home to older people, sleep problems, dementia – all subjects of great importance to readers. Regarding retirement, Jaul tells the tale of a very well known Israeli female singer. The geriatrician estimated her age at about 75 even though she still sang beautifully, was well groomed and moved like a young person.

But when he got closer during a performance, he noticed things that showed she was not ageless: She forgot the order of songs, and her pianist had to constantly remind her. She also had difficulty hearing, and the whole audience heard the pianist’s shouting the name of the next song. The songstress was clearly in need of a hearing aid.

He also recalls a famous surgeon admired by generations of younger doctors. But even though his hands shook so badly, he continued to perform some operations.

As he refused to put down his scalpel and work only as a consultant, his younger colleagues were forced to halt his work completely and send him home.

The author provides much information about the physician’s and the family’s dilemma regarding whether to allow older people to drive.

The author notes that chronological and biological ages are very different and that motivated and active elderly people are able to continue working at least part time and could provide their workplaces with many benefits. Doctors themselves generally prefer to continue in their profession after reaching retirement age. A study published in Harefuah of the Israel Medical Association that he cites showed that many retired physicians were unhappy with their lives due to reduced income and and reduced status, but those who continued working, at least part time, had no such complaints.

If continuing to be employed at the same job is not possible, advises Jaul, keeping busy in hobbies and volunteer work is just as good. As the well-known billionaire publisher and businessman Malcolm Forbes, who died in 1990, once said, “Retirement killed more people than hard work.”