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Update
Update
23 September 2021
19. Cousin Dan, died in nursing home in 2016 at age 95.
19. Cousin Dan, died in nursing home in 2016 at age 95.
Healthy Longevity by Physician's Notebooks' definition is living past age 80 on one's feet with wits and wit. My cousin Dan for the last several years did not quite fit that. My last visit and view of him was in August 2015; then, he had been old-age wheelchair & bed ridden in a nursing home since April 2014. When I last spoke with him, he remembered who I was but that's about all.
Dan was born in 1921. Both parents had normal health for the period and died in their 70s of heart failure. His mother was a rigid personality who believed in all the latest psychological advice for raising a child in the 1920s and Dan, who says he was a weak child, rebelled and was eccentric as adult. He attended the City College
Dan married in the 1940s briefly and divorced. Then single until the 1970s when he met Margaret, a poet, who became his wife and lived in the flat with him until her death from rectal cancer in January 2010 (See the Notebooks 10, Deathwatch chapter on Margaret.) He lived as social security pensioner, $600 a month plus food stamps. Between 2009 and 2012, I stayed several times a year. Since March 2011 he had daily housekeepers to his flat. Since April 2012 he no longer wanted me to stay over. He became angry at me because I had made a key copy for his door key without telling him. I thought it a good idea because it could happen he might fall down when I was out and not be able to open the door. At first I did not tell him about it because I assumed he would not like it. But then it seemed OK and I told him. But it was not OK and so I stopped staying over.
In the first week of April 2014, Dan had an accident in his bedroom. Here is his niece's description:
Dan fell in his bedroom and hit his head in the wee hours of the morning. No home attendant was on duty at the time. (He had only been getting home aide coverage for 6 hrs by day). The home attendant left him the day before at 3 pm - and nothing was out of the ordinary (that she could see).
Dan married in the 1940s briefly and divorced. Then single until the 1970s when he met Margaret, a poet, who became his wife and lived in the flat with him until her death from rectal cancer in January 2010 (See the Notebooks 10, Deathwatch chapter on Margaret.) He lived as social security pensioner, $600 a month plus food stamps. Between 2009 and 2012, I stayed several times a year. Since March 2011 he had daily housekeepers to his flat. Since April 2012 he no longer wanted me to stay over. He became angry at me because I had made a key copy for his door key without telling him. I thought it a good idea because it could happen he might fall down when I was out and not be able to open the door. At first I did not tell him about it because I assumed he would not like it. But then it seemed OK and I told him. But it was not OK and so I stopped staying over.
In the first week of April 2014, Dan had an accident in his bedroom. Here is his niece's description:
Dan fell in his bedroom and hit his head in the wee hours of the morning. No home attendant was on duty at the time. (He had only been getting home aide coverage for 6 hrs by day). The home attendant left him the day before at 3 pm - and nothing was out of the ordinary (that she could see).
Somehow Dan managed to call EMS around 5 am. (Ed: Suggests he was not in a delirium.) EMS had to break in to the apt. to get to him. CVA (Ed: Cerebrovascular Accident; a term for a brain stroke) was determined.
Dan was in a delirium (very confused) during his ER experience at Montefiore Hosp. It took a day or so before he was moved out of ER and onto a hosp. floor. The delirium slowly faded and he became much more cognizant of his whereabouts, etc.
Dan was in a delirium (very confused) during his ER experience at Montefiore Hosp. It took a day or so before he was moved out of ER and onto a hosp. floor. The delirium slowly faded and he became much more cognizant of his whereabouts, etc.
Evaluations did not raise any new issues: He is still hypertensive, hypothyroid. The stroke (Ed: does not sound like he had a stroke) left him unable to balance and ambulate w/out major assist. He is challenged when shifting from sitting to standing also.
As for a prognosis: He has been getting PT and OT, but there is no serious expectation for him to regain independent ambulation. Strength building has been the focus. Dan is overall weakened and more readily fatigued. Fine motor skills are reasonable, able to write, feed himself, etc. He uses a walker to get from bed to toilet, if he is not in a hurry (!) - but more than that distance he is wheelchair bound. He can push the wheelchair a little himself, but he is pushed by an aide to the dining room, PT, etc. (Ed: this is his same condition that I observed for 2 years before this fall)
Short term memory is inconsistent.(Ed: my evaluation in Aug. 2014, it was good but by April 2015 he had lost it) Time and space are not always accurate - but he is usually in the right ballpark. Continence is becoming an issue.
I (Dr Edward Stim) will comment here. The niece, Joy, lives in Texas and had rarely visited Dan in the Bronx. Her description of the event is, I guess, accurate but she really had no idea of his capacities for daily living just before the accident. Dan's big weakness was his gait; he very easily could fall. I observed him to fall several times and once he hit his head. But I do not think what Joy describes was a stroke. More probably he got out of bed to pee early in AM, very groggy, stumbled, fell and struck his head suffering a concussion. A stroke would be expected to cause one-sided weakness and speech disorder, which he did not and now does not have. But because he had no one to assist him the fall ended Dan's 73 years at the the rent-controlled Bronx flat. He then was permanently in nursing home. His condition is barely being able to get around on his feet without assistance but keeping speech, writing and wits.
On 13 April 2014, I telephoned Dan at the nursing home. He recognized me quickly, his voice was the same as I recall these last years and his mind was working well. Also he said he expected to move to a better nursing home, which I take as a sign he still has his critical intelligence. On 26 Aug. 2014, I spoke with him again. He still wanted out of the nursing home and asked me to visit him. He requested I bring a portable electric shaver and 2 roast beef sandwiches that he likes much from the local Bronx deli. Then I called on 31 March 2015 and he no longer recognized who I was even with my prompting and could not say where he was and when it was. His voice was as usual, frail but clear - no sign of aphasia.
In August 2015 I visited him at the nursing home and he was sleeping at 8 pm and I woke him and he remembered me but that is all. He was then totally bed-ridden in a fetal position, unable to take solid food. Sometime in 2016 he died but by then his had been, essentially, a vegetable existence
On 13 April 2014, I telephoned Dan at the nursing home. He recognized me quickly, his voice was the same as I recall these last years and his mind was working well. Also he said he expected to move to a better nursing home, which I take as a sign he still has his critical intelligence. On 26 Aug. 2014, I spoke with him again. He still wanted out of the nursing home and asked me to visit him. He requested I bring a portable electric shaver and 2 roast beef sandwiches that he likes much from the local Bronx deli. Then I called on 31 March 2015 and he no longer recognized who I was even with my prompting and could not say where he was and when it was. His voice was as usual, frail but clear - no sign of aphasia.
In August 2015 I visited him at the nursing home and he was sleeping at 8 pm and I woke him and he remembered me but that is all. He was then totally bed-ridden in a fetal position, unable to take solid food. Sometime in 2016 he died but by then his had been, essentially, a vegetable existence
Of interest, Dan's 5 years younger sister Renee in 2011 died of Alzheimer's. Both siblings shared much of the same DNA and the same years of upbringing in the same flat. But Renee had a long marriage and 3 children and was rather mobile, living in Israel for several years, then up the river in New York State and then in a gated community in New Jersey and finally in Texas with daughter and her husband. It suggests that some environmental factor favored Dan. (Or maybe an infectious factor caught Renee somewhere on her travels.) The differences are children vs no children, mobility vs stability of place, and also difference of gender.
Dan's health always seemed fragile. He was not fat although he had a little pot belly and he was 5 feet 8 inches and Body Mass Index 23. He told me his thyroid has always been weak and in a blood test in 2006 I noted an elevated thyroid-stimulating-hormone level, a sign of mild hypothyroidism but clinically he does not show it. In May 2011 the visiting nurse put him on low-dose thyroid hormone and he reported he feels better from it.
I grew up in the same neighborhood and knew Dan as my eccentric cousin but not close. I got to know him better from year 2000 when I came back to my old neighborhood and rented in Dan's building and since then, especially since 2006 I knew his situation well. His first important medical problem was a fracture of hip in early 2000's and he walked on it for several days before needing to go to hospital and then had surgery and since then he was rehabilitated and had been walking. But since 2006 his gait has gradually worsened into an old person's shuffling gait due to his difficulty in raising his feet high enough to step when he walks. My observation is that the basic problem was weakness of the leg muscles, probably due to combination of muscle unit loss and spinal cord motor nerve units loss due to aging. He did not seem to have a primary balance problem but balanced poorly because his leg muscles were weak. So until his fall that night he got around in house with a walker support and going downstairs but he could not manage to go any distance and needed to be pushed in transport chair. Since Spring 2011 he stopped going out even in the transport chair and even to the downstairs store but that was probably due to having housekeepers daily do all his shopping.
In May 2006 he developed acute complete Atrial-Ventricular heart block. I took him to hospital where EKG confirmed it and echocardiogram showed it due to aging heart. He showed heart failure because of the slow rate and had a pacemaker inserted and since then did well on no medication. (6.18a
Pacemaker Saves a Life - Read it Here! ) His blood pressure sometimes was as high as 150/90 but he refused medication. In 2011 his visiting nurse convinced him to go on an anti hypertension med.
He had cataract eye surgery successfully several years ago. Also several years ago he developed a basal cell cancer of left side of his nose and it grew slowly scabbing as is typical. In July 2010 he had it removed by Mohs microsurgery but they had to take too much tissue so that was followed, a day later, by plastic surgery skin flap from cheek all done outpatient under local anesthesia. He did well, recovering after a month and last I saw (April. 2012) I could not notice anything.
He had cataract eye surgery successfully several years ago. Also several years ago he developed a basal cell cancer of left side of his nose and it grew slowly scabbing as is typical. In July 2010 he had it removed by Mohs microsurgery but they had to take too much tissue so that was followed, a day later, by plastic surgery skin flap from cheek all done outpatient under local anesthesia. He did well, recovering after a month and last I saw (April. 2012) I could not notice anything.
His activities as I observed from 2009 to 2012 were listening to news on his portable radio, eating in the kitchen, and attending to his bill paying and bank balance. I lived with him on and off visiting for weeks at a time from Japan and together with downstairs neighbor Annie we gave him the best life he could have hoped for.
Comment: First, note at age 80, he started healthy longevity not bad but in the last several years his legs deteriorated and it became his major limitation. Until his recent fall, he was barely independent. His mental life was limited mostly by social factors of isolation. If he were in more socially friendly circumstances he could have had a fuller life. He had a desire to continue living based on small pleasures: eating, listening to portable radio.
What factors contributed to his lasting past 90? First, one cannot ignore his life-long attention to healthy foods and vitamins, which verged on fetish. He never smoked or took alcohol or medication (till 2011 when he started medication) or recreational drugs. He avoided salt or sodium, checking food labels, and also tried to take as few chemical names as possible. He ate meat. He ate frequently but not overly. He liked Uncle Sam dry cereal and had it with milk and banana. He ate lots of banana and had total cholesterol 204 mgm but with high HDL 79 (Spring 2011). He liked thick roast beef sandwiches. Also to be noted is the lack of stressful factors in his life. Never had children and gave up regular employment early. Also stability of living place. Always lived in Bronx NY
End Comment on Dan's losing his flat and becoming a Nursing Home Resident: Dan lost his independent life because of the early AM fall and trauma to head. Since Dan's decision to rely on welfare housekeepers and give up reliance of his good Samaritan neighbor, and throw away his trust in me, his physician cousin, he no longer had anyone to really rely on if anything happened. What actually happened in April 2014 was a concussion. Had Dan followed my advice and allowed key copies to his front door for me and his downstairs neighbor, he would probably still be living a semi independent life. But he was too paranoid; he refused to trust his good neighbor and his physician cousin and had a falling out because I copied his door key for the just reason to prevent what happened. The lesson is that when you get very old but you do have a good, honest, willing-to-help neighbor and a physician cousin who wants to manage your case, you should humbly, thankfully accept their help and supervision.
End of Chapter. To read next click 10.20 Murder
End Comment on Dan's losing his flat and becoming a Nursing Home Resident: Dan lost his independent life because of the early AM fall and trauma to head. Since Dan's decision to rely on welfare housekeepers and give up reliance of his good Samaritan neighbor, and throw away his trust in me, his physician cousin, he no longer had anyone to really rely on if anything happened. What actually happened in April 2014 was a concussion. Had Dan followed my advice and allowed key copies to his front door for me and his downstairs neighbor, he would probably still be living a semi independent life. But he was too paranoid; he refused to trust his good neighbor and his physician cousin and had a falling out because I copied his door key for the just reason to prevent what happened. The lesson is that when you get very old but you do have a good, honest, willing-to-help neighbor and a physician cousin who wants to manage your case, you should humbly, thankfully accept their help and supervision.
End of Chapter. To read next click 10.20 Murder
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