Child Resistant Pill Bottles….

Louise Aronson, in her recent book Elderhood, cites the story of child resistant pill bottles to illustrate the casual disregard given to the needs of the elder generation when medical, governmental and corporate decisions are made.

Most of us remember when pill bottles were easily opened.  Children were often rushed to emergency rooms for stomach pumping after swallowing entire bottles of “candy.” My college roommate actually loved the taste of aspirin.  As a child, she had been hospitalized several times because of her ability to find the carefully hidden family supply of aspirin. It was obvious that pills should be more safely packaged. Thus, pediatricians and parents worked with lawmakers to pass the Poison Prevention Packaging Act in 1970, recommending pill bottles like the one pictured here. Almost immediately, the death rate from poisoning of children under five was cut in half.  Success!  Lives saved…EXCEPT

Half of those 65 years old or more have arthritis, a diagnosis which increases with age.  For those with arthritic hands, child resistant pill bottles are so difficult to open that the elderly often chose to leave the bottles open or they transfer the pills to bowls, or worse, they don’t take the medicine at all.  By 1995, 20% of children poisoned found their pills at the home of their grandparents, who had removed their medicines from the child resistant containers.  The Consumer Product Safety Commission met with stiff opposition from lawmakers and manufacturers when they recommended expansion of the testing age from the original 18 to 45, to include testers up to age 75.  Ultimately, CPSC compromised to include testers of pill packaging up to age 70. To underline the point,

it was 1995 before CPSC recommendations for changes to child resistant packaging included testers up to age 70!!

The pill bottle seen above is the current standard for child resistant packaging.  How many 80-year-olds can readily open this container?  What would the container look like if the testors had included 95-year olds?  I consider myself incredibly lucky to live in a senior community where prescriptions are filled in easy open containers. I’m pretty sure I could no longer open the pictured container. 

The point here isn’t really about children and pill containers. Aronson’s message is that public health and medical decisions may be successful for one segment of society, but too often do not consider the impact on the elderly and their health.   There are far more serious situations where the lack of inclusion of the elderly is incredibly dangerous.  Take a look at this graph, which I stumbled upon while researching child poisoning.   The graph tells many stories, divided by age group, some of which are listed below the graph.

JAMA. 2021 Oct 5; 326(13): 1–11. Published online 2021 Oct 5. doi: 10.1001/jama.2021.13844

A few of the many conclusions include:

  • Emergency Department visits due to accidental (unsupervised) child poisonings are about 2 per 1000 population.  That’s amazing! And a sign of the success of the efforts of lawmakers and manufacturers to develop child resistant medicine containers.
  • About twice 4 per thousand adolescents use medications for self-harm and many adolescents abuse medicines.  The mental health of our adolescents is a major public health problem, one not so easily solved with medicine bottle design.
  • The last two columns of this informative chart point out the dramatic number of adults, particularly those over-65  who end up in the Emergency Department due to complications of medicines taken therapeutically!  The causes of this problem include inappropriate dosing, inadequate testing in the elderly and the increasing frequency of co-morbidities in the elderly.  “Iatrogenic illness”–defined as illness caused by medical treatment–is the fifth leading cause of death in the world. Both this chart and common sense would indicate that death associated with iatrogenesis in the elderly is even more common.

The focus on saving child lives worked well for pill bottles.  The 1995 CPSC revision recommending inclusion of testors from age 18-70 was a significant improvement in the health of both the elderly and their grandchildren, even though 85 year olds may still be unable to open the bottle above.  But again, this is merely an example of a systemic problem in which the elderly are overlooked and ignored when safety and efficiacy are under consideration. A far more dangerous example of that deficiency is found in clinical testing and prescriptive doses of medicine, and the entire topic of iatrogenic illness– a topic worthy of its own consideration on another day. 

Politics, Aging, and Auditory Processing

Recent news stories here in Pennsylvania feature discussions of the “auditory processing disorder” (APD) of our senatorial candidate, John Fetterman. As he explained prior to his nationally watched debate with his Republican opponent: “I might miss some words during this debate, mush two words together….” He was provided with a monitor on which he could view transcripts of the questions and his opponent’s responses—but was still clearly struggling. How tragic it would be if his temporary affliction cost him the election, especially given how many of us also suffer from “auditory processing disorder.”

The good news is that the concept of auditory processing disorder as an adult problem has entered our awareness.  Previously, APD was primarily associated with children and learning difficulty, often with autism and ADHD.  One study reports that 42% of children identified as learning disabled have APD. There have been few studies and fewer statistics about the incidence of APD in adults, particularly in the elderly.  And yet, we elders know it exists; we reveal the existence of APD in regular conversation….

  • recently, one of my neighbors asked for computer help, saying that the Geek Squad guys spoke too quickly for him to understand,
  • a long time friend recounted with great sorrow that his cochlear implant wasn’t effective because his “brain was simply too slow” even when he could hear;
  • on our recent cruise, some passengers insisted that the guides speak better English, as their accents made them hard to understand. 
  • My husband and I routinely use closed captioning when watching TV; when we are not straining to comprehend, we are better able to comprehend the plot.

So why is there so little attention on adult and elderly APD?  To some degree, APD is compounded by the inevitable hearing loss in elderly adults –two thirds of those over 70 have hearing loss—and the prevalence of cognitive decline. To quote from a 2017 online publication

“Successful communication and navigation in cocktail party situations depends on complex interactions among an individual’s sensory, cognitive, and social abilities. Older adults may function well in relatively ideal communication situations, but they are notorious for their difficulties understanding speech in noisy situations such as cocktail parties. However, as healthy adults age, declines in auditory and cognitive processing may be offset by compensatory gains in ability to use context and knowledge….. “

We elders regularly see advertisements for cochlear implants, and more recently for hearing aids.  None of these sales pitches mention that the communication problems attributed to hearing may not be simple hearing loss.  Rather, studies and therapies addressing the complex interplay of auditory and cognitive processing in the elderly are desperately needed. Thanks, John Fetterman for helping us “normalize” auditory processing disorder. His APD may be temporary, a consequence of a recent stroke. For we elders, APD has been an un-named, untreated path to permanent cognitive decline.

End of Life is Like A Fine Sunset

To answer the questions asked in the previous post about when and how we disengage from frenzied life, I gathered some very wise responses from thoughtful friends.  I particularly liked these two:

  • Bernard Berenson writes that ‘ the end of life should be like a fine sunset’. I’m not sure that’s what our community fosters, but yet it is what I seek and try to make reality. Our community wants us to keep going and giving and doing. Doing what we always did and more so.That is how many residents see their lives and what administration rewards and recognizes.  

Actually most of us are not at the end of our lives yet. These are our last years, yes. But aware of that as I am, I want to make the best of these last years and to me that doesn’t mean doing what I used to do. It means trying and being and doing something new and, more so, being what I always have been but never took or had the time to realize.

  • Balance in our frenetic world requires paying attention to those signals of feeling rushed, pushed, holding our breath, feeling our shoulders up near our ears.  My mantra has been you have time or there is enough time.  The Dalai Lama long ago cautioned us not to be misled in thinking we have to keep pace with our technical devices.  At another time he advised that There is more to life than increasing its speed. 

Aren’t I lucky to have such amazing, thoughtful friends? 

Return of the Frenetic Life

Even in isolation, it feels like this.

It didn’t take long for the relaxation of the cruise to wear off.  We arrived home on Saturday afternoon, tired and footsore after a long day.  In accordance with our plan, we raced off to the grocery before exhaustion could set in and prepared to hunker down for several days to avoid conveying any errant viruses to our friends. 

Even without any physical contact, it took only a few days to realize how frenetic life in this senior community really is.  The pervasive mantra of “Be engaged” and “give back to the community” has generated wonderful, engaging, can’t say “no” projects.  Indeed, many of us measure our meaning in life by how useful we are to our communities—very much as we all did during our entire adulthood.  Free time had little priority while living up to our potential to engage with the world and its infinite needs. 

But wait, when do we reach the stage of life when we toss off those dragon scales of Social Expectation (a la Joseph Campbell)? When is there time for meditating or reflecting on life and connections, essential to creativity and spirituality and enlightenment (per Buddha, Jung, Richard Rohr and so many more).  Are we, as senior citizens denying aging by staying busy, and carrying our adult expectations into old age?  

Farewell, Insignia            

The real world is approaching on the horizon.  We won’t be in NYC until Saturday, but proximity to home is evident: we have started packing, settling accounts, filling out surveys and departure forms.  Meanwhile, our email is reminding us of home tasks we’ve put off.  It will be good to be home with reliable internet on which we don’t need to take turns, a shower that is maybe three times the size as the one here, and the mobility without “motion of the ocean” to toss us into walls and one another. We are relishing these last few days on the balcony looking out to sea; I’ve read three pretty awful mysteries in these last days and Bob is deep into another of his beloved Saxon tales. Even the time issue is settling down; as of tomorrow, we will be just one hour different (I think).

My blog will return soon to ponderings on aging; I’m already thinking about the decline of cognitive processing skills in seniors.  Before we left, a man I have greatly admired commented with great sorrow that it wasn’t his hearing loss that kept him socially isolated, but his brain which couldn’t process the auditory input even with his cochlear implant.  Another of our residents known for his stubborn and feisty nature called me to ask a simple computer question, explaining that those guys at Geek Squad just talked too fast.  Here, passengers complain about the accents of staff and guides: “we just don’t understand them, your guides need to speak better English.”  That may be partially auditory but I’d bet money that much of their problem is the inability to process the information quickly enough. I’m gathering some data to augment my insights, and pondering the question: Shouldn’t we be talking more about this as seniors?

Before I close this “Transatlantic Treasurers” portion of the blog, it seems fitting to comment on Oceania’s food service, especially as Oceania markets themselves as the culinary experts.  For those who might wish details, here’s a photo of one of today’s menus.

From today’s Terrace Cafe, dinner buffet.

Bottom line: Oceania’s food ranges from good to fantastic. At lunch today, Bob had a sumptuous Moroccan meal, with chicken pastilla, beef kefta in yogurt, aubergine chickpea salad, Moroccan bread, cheese briouates and tabouleh. He polished it off.  The best samosa I’ve ever had was served as an appetizer on the buffet the other day; flaky tender pastry around a perfectly seasoned, moist chicken/potato/pea filling. The Italian specialty restaurant, according to its Italian maitre’d, has an Italian chef who does nothing all day except make pasta, experimenting with items for the newest of the Oceania ships.  I found their Gorgonzola ravioli perfect, and thus was willing to try the egg yolk ravioli in parmesan sauce which was new to me and worth it.  Lobster risotto has been another of my favorites, and my go-to lunch has been grilled teriyaki salmon, crunchy on the outside and moist inside.

Worth commenting upon is the ambience and service in the Main Dining Room and the specialty restaurants. Infinite amounts of silverware and plates left me confused about which was a salad fork, a seafood fork, or a butter fork. We learned to wait for staff to push the chair in, and artfully place the napkins on our laps. The wait crew was attentive, fun and interactive. Upon hearing a passenger express gratitude for small servings, one waiter exclaimed laughingly: “In my Serbia, such small servings would be an insult!” Another time, a waiter teased me that she had placed an entree “refill” order for me which was on its way.  Almost always, we were called by name.  Meanwhile, the buffet restaurant included grill stations and ice cream stations and salad stations and a ton of sushi, along with appetizers and entrees, leaving passengers to roam along the long serving areas to scope things out—not so easy in rolling seas.  Ten feet or so of the serving area was dedicated to unbelievably caloric desserts.  I requested a fruit plate once, and got mango, pineapple, grapes, honeydew, cantaloupe and kiwi. In the buffet, the waiters bring only drinks and napkin-wrapped cutlery.

Hopefully, I’ve left you hungry and with a visualization of why we may roll home….  Again, thank you all for your support and your comments.  See you soon!

Time… it’s all relative

The time is 3:15am at home in Kennett Square according to my Fitbit whose time change technology has overwhelmed me. The bedside clock which our cabin steward usually sets for us says 8:15am which maybe means she forgot to set it last night, because my phone says it is 7:15am and I try to keep it set to ship time. I was awakened two hours ago by Bob’s clicking camera capturing the sunrise. When he saw me move, he cheerily announced that it was 5:15am today, but that it would be 4:15 am at this time tomorrow, as we will set the clocks back another hour tonight. If I weren’t so disoriented, I would toss him overboard—especially since he dragged me out of bed at midnight? to see Orion hanging low in the ink black sky. I have no idea if I have slept at all or well, and now my stomach insists that yesterday’s dinner was long ago and breakfast closes at 9 am.

Help me, please. We arrive in NYC at 7 am Saturday, at which point ship time and Kennett square time should both be 7am. If there is a 4-hour difference now, how many more times must we set our clocks back one hour?

Life at Sea

We are getting closer to home; ship staff want our departure information, clocks are spinning backwards at a dizzying speed and the ship is speeding along at 18 knots.  We are scheduled to arrive in NYC on time Saturday. Here’s how I spent my Sunday.

It’s a good time to tell you about our shipmates, but please keep in mind that generalities are tough when three different groups of passengers have thoroughly mingled.

The original group of 600 departed NYC after numerous cruise trips had been cancelled due to COVID: the “COVID pause.” Many of these 600 were anxious and impatient to get back to sea, booking additional cruises this year to feed that hunger despite the continued danger of COVID.   About 300 of these original travelers were replaced in Reykjavík by equally anxious “experience-seekers” who kayaked, hiked, and/or dined in cool places during our brief stops. Most of that 300 left the ship in Le Havre, too impatient to handle all the upcoming sea days.

The 300 or so who boarded in La Havre included some who had been touring Europe for weeks on their own, others whose primary interest was just being on the ship, and some who were using credits from previous trips or adding trips for their loyalty rewards. 

Most of these travelers are frequent travelers with 40 or more cruises under their belt.  Conversations typically start with “Where have you been before?”  Passengers arrive and mostly stay in couples (friends, partners, grandparent/grandchild). Most are repeat cruisers (as in 40 or more cruises under their belts.) We didn’t try to socialize at first; telling our COVID story wasn’t good conversation when COVID was roaring through the ship, and Bob’s cough has been disruptive until recently. We learned that in this COVID time, most socialization is on buses or in small-group ship activities. In the dining rooms, tables of four or six are the exception; large tables remain empty while 2-person tables fill quickly.

A few of the stories we’ve heard are just plain sad: “My husband and I were planning this trip together. He died of COVID, and I decided to come anyway.” “My mother just died; we had planned to come together. My family said I should come to honor her.” “I was asked to accompany a 90+ year old; he bought a 2-year suite ticket for us and died on the ship after just a few months.  I am finishing the trip.” Some passengers have portable electric wheelchairs, many have canes, there are both deaf and blind passengers on board and some who are clearly demented.

Oceania Insignia has a laundry room, used by all who don’t get free laundry with their upgraded room choice.  Always busy, the laundry room is the source of great gossip. “Two men got into a fight on an earlier cruise about whose turn for the dryer was next and were subsequently disembarked from the ship.”  “There were 30 or 40 or 50 or maybe 100 COVID cases earlier in the cruise.” “There is no COVID on board now.” None of that may be true.

Dress, except at dinner, is more like COVID comfort than Country Club casual: shorts, t-shirts, sandals. Folk “dress” for the dining room and specialty restaurants with slacks, shirts and shoes and occasional jackets or fancy shawls and tops. Hardly any jewelry.

Maybe tomorrow, we can touch on food.  Or maybe I’ll just read another mystery on the deck….As I finish this blog, a diversion from my original “aging” blog, do let me know if you have questions. Once home, this will all be in the past.

Lunch on the outdoor buffet restaurant as we left Lisbon. It was a beautiful day.

Lisbon: We hardly knew you

Sadly, our visit with Lisbon didn’t give us opportunity to fall in love with it. Our ship was in Lisbon only from 7 until 2:30; traffic, crowds were terrible; and our tour guide was adamant that we visit the iconic sights. I did enjoy the Lisbon sights which reminded me of our trip to Brazil more than ten years ago; I will share the iconic sights with you (briefly) and the reminders of Brazil.

Brazil taught us to say “Obrigada” for “Thank you”, to really see the incredible tiled walkways, and to laugh at the many jokes about the huge Christ the Redeemer statue in Rio de Janerio. (In Argentina, the snarky joke is that Christ will raise his arms when the Brazilians go to work. Click on the link for more of the Brazilian jokes.) The tile work is laid down by workers, piece by piece, and repaired regularly. Here are some examples:

We saw very little of the tilework on buildings, in contrast to the amount in Porto City. Lisbon experienced earthquake, tsunami and fire in the mid-18th Century, and much of their early architecture (including 150 churches) was lost. Our lecturer also noted that Porto City was more mercantile and less royal than Lisbon, and that merchants were more likely to flaunt their wealth with tilework on their homes.

It seems that a Portuguese priest visited Brazil and decided Portugal should have its own Christ the Redeemer, for which he then raised the money. Sitting across the Tagus River, and beside a bridge strangely similar (and locally called) the Golden Gate bridge, here are some photos of Lisbon’s Christ the Redeemer:

Cranes and construction, as in Port City, were everywhere. Again, hotels are replacing banks and transportation is being adjusted to better route tourists to the iconic sites. Unfortunately, another reminder of Brazil were the high-pressure sales tactics of numerous street vendors and the warnings of pickpockets. There was a visible police presence in those crowded areas.

Upon our return to the ship, the Captain announced that Lisbon had been our last port. The planned trip to the Azores would have brought us directly into the path of Hurricane Danielle. Onward to NYC! The sea is beautiful, the sun is bright, and my deck awaits….

Porto City, Portugal – One of tomorrow’s top ten cities?

It would be sooo easy to write the marketing copy for Porto City (as the locals call Oporto). First, I must acknowledge that I know nothing about Portuguese economy or politics…but all of the ingredients for a favored tourist spot are already in place:

Great historical attractions: Forts in beachfront settings, the well-known tiled homes and churches (and lesser known tiled interiors in public buildings).

Modern architecture and street art.

Construction. 

Quirkiness.  What other European town has both a bookstore where one must stand in a very long line to get entry tickets and also a 16th century jail graced with a huge statue of a favored author holding his nude mistress?  (It seems that JK Rowling did some writing in the bookshop and it’s been mentioned in guidebooks as a “must see.” The statues portray a couple who served time in the jail for adultery: he on the nicer third floor; she relegated to the less nice 2nd floor.

Stunning beaches.

I love this photo, so you are seeing it twice. This time, notice the beautiful wide public beach.

Of course, there are a lot of tourists taking pictures already….

Looks like a tourist to me!

Porto City is famous as the home of Port Wine, almost an afterthought for this marketing list.  Given that red wines give me instant migraines, we didn’t even pursue a sip. The story we were told about the development of Port by a British fellow (who fell off his boat after a Port Party on his estate and drowned because he had a money belt filled with gold. Seriously….) is just one example of a longstanding bond between the UK and Portugal.  Clearly, the UK is heavily invested in Portugal still. 

Tomorrow, Lisbon and Sunday (Sept 4) the Azores.  Then it’s due West for five 25=hour days to NYC.  We should be totally disoriented to time and place as we leave the ship on Saturday the 10th and grab the train home.

Ferrol, Spain – A break before the final push        

I chose not to visit this medium-size Spanish town, whose primary tourist attraction is its naval base, huge shipyard and proximity to the Camino de Santiago walk.  Instead, I enjoyed total solitude on our sunlit deck, listening to gulls and watching small single-person rowboats quietly fishing for squid. Bob checked out the shipyard, and was suitably impressed with the 600-foot drydock and the sad story that joining the EU resulted in the closure of that shipbuilding business and the subsequent layoff of 40,000 workers.  The town is struggling to become a tourist destination, but it’s not there yet. 

Ferrol, Spain: calm, peaceful despite being a naval base and armory

We are indeed in the final week of our cruise, more or less. I am starting to think about whether we need to do laundry again, and about ground transportation in NYC from the pier to the train station. I worry a bit about the insurance forms and the medical follow-ups but mostly I am still here and enjoying. I do check email, so we do know that the willow oak for the area behind our cottage has been purchased (thanks Janet, Beth and Kathleen!), that COVID is back in the Health Center, that the laundry fire caused consternation and inconvenience but no major problems. None of that seems urgent or even nearby. We might tire of this floating full-service window to the world after a while, but we aren’t homesick yet.