One of the most interesting and troubling aspects of dementia is the idea that there can be a complete shift in reality in the mind of the person diagnosed. As family members and caregivers, how we react to and interact in that shifting reality is paramount to what might be seen as a good day or a bad day.

What comes to mind first, and in fact is listed first in every list of dementia symptoms, is the memory loss. First the short term, and then the long term memory fades.

Other symptoms: Problem solving and difficulty planning even routine tasks is noted by family, friends, and co-workers. Visual perceptual changes can become apparent and a dark rug can look like a hole in the floor. Someone with a dementia will have confusion about time and place, not just getting the year wrong but also thinking they are 40 years younger than they are. Misplacing things is not uncommon and the person with dementia may even hide things in unusual places, often to keep them safe. And there may be changes in personality and in mood.

But most intriguing to me is the idea of a changed reality.

Last summer we would help my mother down the 150’ path to the deck over-looking the lake on which she has spent more than 50 summers. Looking mostly at her feet the entire walk down the path she was aware of the risks ahead, rocks, tree roots, leaves. A gravel strewn path through the woods. Gravel we put down to smooth out the uneven route to the water she knows so well. And as we approached the deck she would, at times, look up and ask “whose lake is this?” And when we replied that it was “our” lake, her answer was “oh, but we must be further down on the lake.” So even though she had just walked a mere 150’ from her house, to her deck, on her lake, it was not, in her mind, familiar.

There are classic examples of women with dementia certain that a doll is their child and days are spent nurturing the baby. A man who takes apart all of the sinks in a facility because he was a plumber and he is fixing the plumbing problems for everyone. People who look in mirrors and can’t identify who the old person is looking at them since they are, in their mind 40 or 50 years younger. Many memory care units take all of the mirrors down.

We finished the summer on the lake in Maine and I offered to help drive my mother and father back to Florida. This is a trip they have made for the past 21 years and this was the first time they needed any help.

Best to follow a familiar routine so we headed out and the plan was to stay at Hampton Inns along the way. Numerous stops were made as all 3 of us benefited from breaks for food and the restroom. Each time we stopped my mother would tell someone that there were 2 more cars with my sisters and their families following us. And each time my father and I would share the truth. No, we were the sole car in the “caravan.”

We checked in to a Hampton Inn in Delaware and went out to dinner, again stating to the hostess that that it was just the 3 of us despite my mother’s claim to needing a bigger table. At 9:30 pm my parents went to their room and as I entered the door to my room next door they asked me to wake them at 6:30 the next morning to get an early start on the next leg of the trip south. I slept well and went next door at 6:30. Mom proceeded to tell me how she heard knocking on the door in the middle of the night. Assuming it was 6;30 and me coming to wake them she got up to let me in. Instead she was confronted by a naked man, yelling that he had to get in their room. Mom said dad went to the door, pushed him and raised his flashlight to hit him but her retreated. And she said “luckily it was all caught on video camera so everyone knows we are telling the truth.”

I turn to dad thinking mom had really lost it. But no. He confirms. A naked man did get locked out of his room and my parents just happen to be the hotel guests across the hall! Reality meets dementia.

Once on the road again my father picks up the phone to make a reservation for a Hampton Inn in South Carolina. From the back seat my mother says “Make sure you get the naked man discount.”

Picnics, parades and fireworks, the things that Independence Day brings to mind as we approach July 4th. We really have no connection to the battle for independence that went on so long ago. Because although our independence was declared on July 4th (really it was July 2nd) 1776, there was a great deal that went in to achieving independence following the declaration.

And do we give much thought to the battles that have been fought since then so that we might continue to live in independence? Probably not.

I am in a great position to acknowledge the heros of the long ago battles as through my job with Seniors Helping Seniors of New Hampshire I am blessed to hear the stories of service in the name of independence. Sometimes they come from the service man himself and sometimes from a surviving wife or child.

I have met a widow and son who shared the story of the father serving in the Navy during WWII. He was in charge of locating and detonating mines before the ship ran them over and was blown up. At one time during this process something did not work right and the missile that would detonate the mine was jammed. Realizing just in time he acted quickly to stop the ship from moving further forward. Consequently the ship’s captain fell and broke his nose. The story goes that the serviceman was court-martialed however reason prevailed and it was acknowledged that a captain’s broken nose was better than the deaths that would have occurred had the ship continued forward.

Another gentleman tells of his family’s escape from Germany in 1939 on the last boat to reach Israel safely. In 1948 he served in the Israeli Defense Force in that country’s War of Independence. He was 19 and his sister was 16, both firing machine guns in the name of freedom.

And another senior we serve, so thin now his pants fall when he stands up but rightly proud to have served on the beaches of Normandy.

We visit daily with a woman who cannot recall the names of her children or how long she was married but she gazes at the flag folded and framed and hanging on the wall in the living room with the proud knowledge that the man she loved served his country.

These and others of the generation serving in WWII and Korea are now in another fight for independence. A battle to maintain their dignity and respect as they face old age and all of the complex conditions that come with it. The men and women who served in Vietnam are not far behind them.

As we all begin to face the task of caring for our aging parents, relatives, and neighbors we must remember that they deserve the fireworks, the parade and the special seat at the picnic. They fought for independence and they fight for independence still.

I was struggling to reach the higher branches with the extending tree saw and clipper when my 16 year old son, Mitchell came out to see what I was doing. I had stood and stared at these low hanging branches of the neighbor’s oak tree from various angles, both on the path and from the kitchen window and today was the day I was done with them. They obstruct the sunlight and I get the lion’s share of the acorns in the fall to pick up. So I had decided to cut these branches off and let the light in.

Mitchell is taller and stronger, a fact that sneaks up on you as a mother. One day you just realize your child is bigger, stronger, better than you are at these types of jobs. After clipping one branch he was ready for the rest. He liked the challenge of getting through a bigger branch farther away and controlling the swing of the now 15’ saw as it broke through and the limb came down. Bigger, stronger, better.

So I watched him, proud, and with time to think about this. I got to thinking about neurological pruning and life and aging.

When we are born we have more than 100 billion neurons which are the nerve cells of the brain. This is more than we will ever have as we go through a process of creating connections, strengthening connections, and also discarding connections in our brain. These connections are called synapses and except for the synapses that govern basic functions like breathing, heart rate, sleeping and eating, they develop after birth. They develop in response to our experiences and represent learning. By the time we are 3 years old we will have ONE THOUSAND TRILLION synapses! By the time we are teenagers we will have discarded half of these. Some parents will argue that it is more than half but that is another blog.

I have always liked the example of patching a weak eye of a child. The weaker eye is patched in order for the child to use it, creating connections in the brain, or synapses, before they are discarded and that eye remains weak.

This process of discarding synapses or connections is called pruning. It is extremely important so that we can function without being overwhelmed. We prune synapses to let the sunlight in and reduce the amount of useless “stuff” or acorns that fall on our life. Our lives actually become richer and fuller as our brains organize.

It would be great if we could treat this neurological pruning process like a bonsai. Select a small branch here, something we no longer need, a small branch there, an activity that does not fit and keep the basis of what will create longevity and a desirable shape to the tree of our life.

In fact to a certain degree we can. When we prune a tree in our yard or a prized bonsai in its pot we choose to keep the portions that are going to create value and we cut away that which does not contribute. So, what do we keep?

• Intellectually stimulating activities like Crossword puzzles Sudoku, Learning something new like a language, Reading

• Physical activity such as walking, hiking, swimming

• Maintaining and engaging in relationships with family and friends.

• Eating healthy

• Spiritual engagement

Those are the branches to keep. Exercise our brain, exercise our body, slow down the pruning of synapses.

What do we prune away? Many experts feel that our 50s and 60s are a time to give up unhealthy habits. Overdrinking, smoking, overeating.

I would bet if we took the list of things to keep as a basis and built our lives around these we would find fewer acorns and more sun on the path.

Courtesy of Inmagine Google Images

My mother started to express a fear of falling 10 years before she had her first fall.  She and my father were active people, playing golf 3 times a week right up until she was 79 and he was 81.  They have lots of friends and were always out doing things; popcorn night, Elks Club dinners, a cruise to the islands once a year, evening rides on their pontoon boat at our summer home in Maine.  But her steps started to look different.   Her gait pattern was changing and before my eyes, her daughter and  also a physical therapist saw that the future could easily be a fractured hip.

Fear of falling in seniors is the number one risk factor leading to a fall.  As we begin to worry about falling and all of the complications that go along with a fall in our 70s and 80s, we change the way we move.  People with a high level of anxiety about falling are most likely to suffer a fall, as noted in a 2010 study conducted in Sydney Australia.  http://health.usnews.com/health-news/family-health/bones-joints-and-muscles/articles/2010/08/20/in-seniors-fear-of-falling-risky-in-itself

About one third of the elder population over the age of 65 falls each year, and the risk of falls increases proportionately with age. At 80 years, over half of seniors fall annually. Those who fall are two to three times more likely to fall again.  Fear of falling leads to a restriction in activity which leads to weakness, which leads to a justifiable reason to be afraid of falling.  The cycle has to be stopped early.

My mother continued with her social activities but took the golf cart more often.  She shortened her steps and changed the way she went up and down stairs.  In essence she created what she feared.  Talking to her about her fear did not help much.  What she heard when we talked about fear of falling leading to falls was a prophecy of her future.  She heard “you are afraid of falling so you are going to fall.” What was meant was “you are afraid of falling so let’s change the way you move to better prevent a fall.”

To be fair, my mother has had rheumatoid arthritis for 35 years, she had back surgery, a laminectomy at 69 followed by a small stroke from both of which she had an excellent recovery.  My mother did begin a home exercise program that I taught her, modified somewhat for her arthritis, but once up and about for the day she stopped pushing herself physically.  Walks were shortened and then became absent.  Her gait pattern changed with her feet closer together and her stride length shorter.  And then the fall came.

My mother had a larger stroke at 79, leaving her slightly weak on the left side.  8 months later she dropped her toothbrush on the floor and bent to pick it up and just kept going forward until her face and hands hit, followed by the rest of her.  An ambulance ride, x-rays, and consultation with orthopedics revealed broken fingers and very bruised facial bones.  No fractured hip.  One blessing.  Once home the response? Increased use of the wheelchair, decreased walking, increased immobility, increased muscle weakness.  All out of fear that now was a reality for both my mother and my father.  He was happy to have her in the wheelchair.  It broke his heart to see her bruised and hurting.

In retrospect I should have done more education earlier.  I should have been a meddling daughter after the back surgery and called her doctor, insisted on physical therapy for her then.  I should have recommended regular exercise class.  She needed more than the 10 minutes a day of exercises I gave her.  Granted 10 minutes of targeted exercises are better than nothing but they need to be combined with the consistency of  walking, swimming, tai chi, or any other senior modified exercise program.  I lived too far away in New Hampshire so each year that summer arrived and my parents traveled north from Florida for a summer in Maine I grew more and more alarmed.   I made gentle recommendations but now I wish I had raised a loud red flag of concern and asserted myself as a physical therapist first and daughter second.

What does this mean to you?  Learn from our journey.  Start early and do not let up.  Recognize that you have to stay mobile to stay mobile.  Yes, do some home exercises, a good start was recommended in earlier blogs.  Look for a class conducted by a professional with experience with seniors.  This could be a physical therapist, an athletic trainer, a tai chi expert, a yoga instructor but be sure that the professional knows how to safely modify each exercise for seniors or for an underlying condition like arthritis.  If you have a fear of falling ask your doctor for a referral to physical therapy.  Chances are you have some underlying weakness and in 4 to 6 visits you will have greater confidence and an individualized home exercise program to keep you going.  They may also know of a good group program to continue with once discharged from PT.  Even finding a walking partner in your community helps as you will both keep each other motivated even in cold New England winters.    Overcome your fear of falling and decrease your risk; step out in confidence.

As we age we stop performing many activities that came naturally at a younger age.  Think about it, when we were in elementary school we ran on the playground, climbed up the ladder of the slide, crawled through play tunnels, hid in bushes during hide and seek.  We played on the floor, on the grass, and in trees.  I like to say that we were “multi-level players.”  Add 20 years and we were multi-level parents.  We bent down to pick up our child after a fall and a skinned knee, we bent down to get a hug, to pick up our child and carry them up to bed.  Maybe we knelt by the side of the bed to say prayers.  We definitely bent down to pull a favorite stuffed animal out from under the bed, or at least a sock.

Then our children grew, we stopped picking them up.  We approach retirement and we rarely live our life on multiple levels anymore.  This seems convenient; we sit on chairs and not the floor.  We arrange our kitchens and work room so that everything we need on a daily basis is somewhere between our belly button and our ears.  We are so smart.   And so efficient.

But we could be too efficient.  We are limiting our movement each day and the old adage “use it or lose it” applies to muscle strength and range of motion.  Range of motion describes that amount of movement we have around a joint.  As we age our muscles begin to lose mass because of a decrease in the number and size of muscle fibers.  As senior care service providers we will only maintain or gain strength through the range that we use.  So over time the muscles that we use to reach for needed items weaken, the muscles that we use to squat and return to standing weaken.  And what we don’t know is that these large muscles of our legs are muscles that are essential to balance and mobility.   Strength in these muscles helps us right ourselves quickly when we have had a misstep and begin tripping.  They help us to get up and down stairs and curbs safely.  They help to prevent back strain when lifting.

The last exercises helped us to prepare for the day, to wake our muscles up, increase circulation, and to lengthen what is likely getting shortened.  In addition to these, in caring for ourselves as we prepare to care for seniors,  throughout the day it is important to incorporate a few exercises that will maintain our strength, and in particular to maintain the strength in our antigravity muscles since we have determined that gravity is working against us.

Start facing a chair or counter.

March in place, placing a hand on the counter or chair only if you need to in order to feel safe. March for a minute, take a break and march for another minute.  If that is too much, march for a count of 10, take a break and march for another count of 10.

Keeping your knees aligned over your second toe, slowly sit back as if you are going to sit in a chair. Lower only as far as you can go and still feel control, making certain that you do not become “knock kneed” that is, your knees do not move towards each other but stay centered over your toes.

If the exercise above, sitting back towards a pretend chair, is difficult, reverse the exercise.  Sit in a chair and slowly come towards standing.  Then slowly lower back to sitting.  Again, keep those knees over your toes and do not let them come towards the middle.

Keeping your knees aligned over your toes is important for the health of your knees.

Facing the counter or chair, rise up on your toes, hold for a count of 3 and lower.  Repeat 10 times.  Work up to 3 sets of 10.

Now in standing, pull your toes up towards your legs, lifting the toes and forefoot off of the floor.  Hold for a count of 3, repeat 10 times.  Build up to 3 sets of 10.

These chair or counter exercises are going to go a long way in keeping you strong for the day as a care provider for seniors or in caring for yourself.  In a perfect world we do all of the exercise together, starting with those I described for you to do at the start of the day before getting out of bed.  But I have yet to find a perfect world here on family-raising, chore filled, work laden, gravity pulling  earth.  Do them as you have time.  One exercise in 30 seconds to a minute is better than no exercise at all.  We tend to feel if we cannot do everything we will not start at all.  Not true with a home exercise program.  Do what you can when you can and your life will begin to feel easier, pain will be reduced and endurance will increase as you move more efficiently.

As a senior care service provider, you won’t be able to take care of others if you don’t take care of yourself! Developing some good stretching habits will go a long way toward keeping you more mobile.

Randy is 6 feet tall and I did not know him as a child but he must have grown quickly. He got Osgood Schlatter’s Disease, a knee problem, as a teenage and limped for a year – not uncommon when you grow fast and are trying to play hockey. Randy does like to point out that he was the worst player on the 2nd string of the worst team in Maine. What he had for 40 years of his life was tight hamstrings, which led to back pain, knee pain, neck pain, shoulder pain. You get the idea.

And then a brilliant physical therapist (not me because I am his wife and not his physical therapist) taught him to stretch his hamstrings. So for the past year at 6:45 am he has taken our dog Moses to the field down the street. As all of the neighborhood kids wait at the bus stop, Randy chucks the tennis ball for Moses, throws a foot up on a boulder, and carefully leans forward, keeping his knee and back straight.

Holding, holding, holding.

Foot down, pick up the ball, chuck it, repeat other side.

Repeat 3-4 times a day.

Happy that his 15 year old step son is unaffected by how strange he may look on the field across from the bus stop, Randy’s pain is gone. He is convinced that he has found a cure for all afflictions, including hair loss.

Stay Limber in Your Hamstrings

In my first blog I taught you how to do 7 simple exercises to start your day and maintain strength to combat the effects of gravity on the aging spine. But I also mentioned that stretching your hamstrings is another key. As your hamstrings shorten, your pelvis is pulled under, creating tension up your spine. All of the way up the chain you will compensate for this tension. So you should and you can stretch your hamstrings and this will help your mobility and counteract gravity pulling you down every day.

The exercise below is different than the one Randy does in the field but it is easy, and most importantly it is difficult to do this one with poor alignment as the bed or floor will serve to stabilize your spine:

• Lying on your back, bring your right knee towards your chest. Keep left leg straight on the bed.
• Place both hands behind your right knee and slowly straighten your knee, bringing your foot towards the ceiling.
• Hold for 3, bend your knee.
• Repeat 10 times both legs.

For some other tips on how to stay limber as a senior, visit this link.

At 27, when I was pregnant for the first time, I was working as a physical therapist with infants and young children and my entire world perspective was one of disabilities at birth. In my 40’s, with 3 children and 3 step-children – all except 1 being a teenager – I was working with young adults with traumatic brain injury. All I knew was that drinking, drugs and driving result in injuries too overwhelming to describe here.

And then I moved into the world of geriatrics and I have begun to realize that if other stages I was looking at through my physical therapist’s eyes were out of my control, this might be a stage I could do something about. And there is still time, this is my future. This is your future. We will likely all reach a place in our lives when we are providing care of some type to a senior. Our parents, our grandparents, a neighbor, a member of our church; with 10,000 to 11,000 people reaching 65 every day and with so many living beyond 80, we will know and love a senior who needs our assistance. As a senior, as someone approaching the age of seniority, or as a senior care provider staying fit is vital.

Gravity is mean to the aging. We shrink, we curve over and forward, and our decreased muscle mass struggles to keep us up. But I believe the secret to counteract gravity is extension. Randy, my husband believes the secret is stretching your hamstrings.

Either way, and probably in combination, we have to move.

Start at the beginning of the day. Everyday. Before getting out of bed is a great time to begin to warm up our muscles and increase circulation. This will help to lubricate our tendons which attach our muscles to the bones. As we age these tendons lose water content, making us stiffer and less able to tolerate stress.

The following exercises will help to decrease stiffness and increase joint mobility before we even get out of bed:

1. Stretch out long and tighten all of your muscles, relax, tighten, relax.
2. Windshield wiper your feet 10 times
3. Bend your knees and with your feet on the bed, gently draw your belly button towards the bed, still breathing. Lift your buttocks hold for 3, lower. Repeat 10 times.
4. Drop your knees gently to one side and then the other. Look in the opposite direction.
5. Roll to your side and rise to sitting at the edge of the bed.
6. Squeeze your shoulder blades down and back. Hold for 3. Your breastbone should tilt up when you do this. Repeat 30 times
7. If your ears are forward of your shoulders, tuck your chin but do not tilt your head, bringing your ears over your shoulders. Hold, relax, hold relax.

Senior care service providers–Now get up and get your coffee. And no, we did not stretch your hamstrings. We will add that next time.