Tuesday, November 18, 2008

As We Grow Older... Thoughts on Coping with Ageing

"A man's age is something impressive, it sums up his life: maturity reached slowly and against many obstacles, illnesses cured, griefs and despairs overcome, and unconscious risks taken; maturity formed through so many desires, hopes, regrets, forgotten things, loves. A man's age represents a fine cargo of experiences and memories." ~ Antoine de Saint-Exupéry, Wartime Writings 1939-1944, translated from French by Norah Purcell

My father had a fall the other night.

He'd slipped and tripped over his own feet when getting up and sidling past the lower corner of his bed. He'd bumped his head and left eyebrow on the hard tiled floor and sustained a small cut which oozed some frightening amount of blood, especially to the unaccustomed eye.

My mum was fast asleep on the other side of the bed, after having taken a mild anxiolytic because she had been sleeping poorly. She'd awaken groggily with a shock.

I'd heard a thud from outside his room, and rushed in to see him lying on his side cradling his head and his bleeding wound in his bloodied hands, amidst a small pool of blood on the floor. He was conscious but appeared stunned, perhaps he was whimpering so softly that it appeared quite alarmingly soundless. It just happened that I was downstairs, preparing for bed, after going through my last emails of the day on my macbook—it was almost 12.30 after midnight.

Father is 79. We'd just joyously celebrated his birthday on 25 October this year at the Peking Restaurant in Johor Bahru. Nearly everyone of our extended families came and converged to reminisce on and rejoice in our better-than-average fortunes and re-engage our peculiar if fairly tight family dynamics.

Dad has had hypertension for more than 40 years, and now has some moderate disability because of Parkinsonism, and perhaps a sneaking creep of the 'D' word--dementia...

Dad and mum have been staying with us since mum had her bypass surgery in June 2008. Of course from time to time, they also stay with my other brother, Tom in Johor Bahru. Although they wish they could soon be on their own again in the comfort of their familiar home, they realise this possibility is becoming more remote as time passes.

I think the unthinkable and the feared realisation that they are day-to-day facing greater difficulties in independent living, is sinking in. And this painful awareness is all the more frustrating and despairing, that age has stealthily tiptoed into and finally robbed them of their sense of self-reliant self-sufficient worth and maybe even dignity, much as we, their children, try to ease their entry into another phase of their lives with us, who can accommodate them...

Mum has despondently lamented in expressions which I can only try paraphrase: "It's not quite the same, what about my closets, especially my inherited one-of-a-kind vintage prayer-armoire; my bric-a-bracs: my extensive collection of fridge magnets, souvenirs and mementos from my children, my grandchildren, etc., my personal effects, my memories, my narratives, my personal space, my personal me, and 'us'?"

Indeed, what do we do with our lived and collected memories as and when we grow older? Do we simply discard them? Do we de-clutter our lives wholesale, toward sanitised and efficient living, devoid of these abstract but possibly humanising touches? Do we live on in a staggered sequential vacuum, or do we add on to our own experiences and those of our forebears? Shouldn't our lives be ever enriching and moving upwards in our hierarchy needs of humanity and its anthropic enlightenment?

Dad also suffers from some form of dyskinesia probably as side effects from the anti-Parkinsonism drugs he's taking. The coarse repetitive tremors are fewer, but the involuntary sinuous movements and sporadic jerky twitches seem more evident. These movements appear pointless and sometimes disturbing to the extent of making him unsteady on his feet. They sometimes disturb his hand to mouth movement during eating and drinking. Putting on or taking off his clothes are also more of an effort, with faltering coordination and triggered instability.

But there is perhaps more than meets the eye. As a medically-trained person, I sense there is more than what he is going through quietly, but I'm quite clueless as to how to elicit from him, what he's truly feeling and thinking. I sense the occasional but more frequent muses of his confusion and his frustration. I ask and try to pry with sensitive but discreet queries, so as not to alarm his sense of loss or heighten his fear of the unknown. What can one do to ameliorate that creeping sense of uncertainty, that progressive withering of hitherto reassuring concreteness of one's life? Can we hope against all reasonable hope to reverse or retard such a debilitating sense of petrifying, emasculating loss?

In the evenings when we sometimes have had some quiet time to talk, he has expressed in tortured exasperated tones, on more than a few occasions that "I don't know what's happening to me; why is this happening; why won't someone explain what's going on with me? Tell me what's happening to me." But more often than not, he sometimes withdraws into a disquieting silence, retreating into his contemplative if vacuous sanctuary, with his stooped shoulders, half-closed eyes, and seeming distractedness. Yet there are sporadic mutterings, too—most often inaudible, incomprehensible and sometimes incoherent...

He occasionally mis-senses his surroundings, claims that there are images of persons about him (children, old friends, neighbours) when there are none, but quickly acknowledges that perhaps he was mistaken, when challenged... He says he sees, he hears, he senses, sometimes at odds with the physical world as we know it, yet he is neither frightened nor spooked out—he just accepts the confusion of his senses, his misaligned realities... His world must appear changed: his perception less sure, less defined, more nebulous, more metaphysical, perhaps even surreal.

Father certainly has aged, he has slowed considerably and more often than not appears understandably less sure of himself, particularly these last 2 years. I suspect the long-standing hypertension must have exerted its silent toll on his nerves, the neurohormonal balance and their complex connections...

He has become forgetful, although his remote memory is still surprisingly sharp and astute: when we were discussing my last school reunion with some of my childhood friends, he remembered that the few of us then, were always competing, and that our Biology projects were so engrossing with us then—he remembered the maize-growing project, our ecology pond study, my pencil drawings, my book projects, etc. Astoundingly, he could remember these so well, so remarkably accurately... No, Dad is anything but that far gone—thankfully, he remains lucid and altogether with us most of the times, especially when you engage him with meaningful conversations.

But this is not so of some of his more recent memories. He misplaces his clothes in the closet, his wallet, and especially in the evenings when darkness sets in, he would be in his most confused moments—losing direction even about his bedroom and the en suite bathroom. Because of his prostatism (enlargement of his prostate gland resulting in disturbance of urination), his nocturnal urgency and frequency also dictates that he has to 'search' for the rest room more often, but also sometimes erroneously, even though it is just a few steps away.

As someone who may know a little more of what is happening, it is also gut-wrenching to watch someone you love, one you'd looked up to and categorically accept and respect as an authoritative singular figure, slowly fade away from his prime of being the man of the house. One can recognise the gradual if irreparable attrition of one's personality, one's mind, one's sense of individual worth and entity, one's dignity, and yet feel so hopelessly inadequate to stall, or to try reverse that ebbing tide of sentient loss.

The retreat and the withering of one's fully-functioning mind and faculties must rank as one of the most dehumanising aspects of ageing. For man, this erosion of the capacity to exert one's complete control over one's thoughts and actions must be exasperating and dispiriting, amidst the angst of unfathomable forgetfulness and vacuity that potentially awaits the ventricular and groove enlargement of the brain, and the shrinking thinning white matter...

Yet we know that as we grow older, we will inevitably deteriorate—biological entropy and decay seems inexorable. We lose our capacity to repair as accurately: our cells and organs become more error-prone, our rehabilitative responses fail to keep pace with our programmed cell deaths.

In our brains, similar degeneration can take place, sometimes accelerated and rapid, but for many, these may be gradual and at least in the beginning, sputter in flashes of disrupting fits and 'awakened' spurts. Our microglial cells (the brain's repair and janitorial system) become increasingly hyperactive and may indiscriminately attack adjacent normal neurons and its sheaths—clipping new connections, forming tangled scars, creating neural 'holes'. Thus, grey matter of the brain atrophies: scars, tangled knots (neurofibrillary tangles), amyloid beta peptide degeneration (Aβ40, Aβ42) replace our neurons, their multiple dendritic connexions become disrupted, interrupted, and our myelin sheaths (the nerve outer linings which control speed of nerve transmission) break down into disrepair, etc.

These neural memory templates fade especially those which are recently encoded, leading to recent memory disruptions which can incapacitate and frustrate day-to-day cognitive function. Movements and actions slow down and become faulty and dis-coordinated. With time, this memory retreat can recede so far backward in time that only childhood remembrances remain—children, spouse and other loved ones are forgotten to the desperation and chagrin of the lost...

Sometimes, the creeping dementia gratefully erases the personal psychological distress which often accompanies the earlier stages of this deterioration. Finally, a blissful if ignorant world remains—a sort of a tabula rasa reversed. At other times, the anguish can be especially tormenting mentally and psychologically enervating. Then, some sufferers may even be desperately suicidal. Many however, retreat into a child-like state, becoming increasingly incapacitated until they have to be fully taken care of in every personal and social detail...

How then can the elderly and care-givers cope? What do the aged desire? It has been said that they desire 1) a sense of meaning and purpose; 2) freedom to make their own choices; 3) a sense of belonging to family and community; 4) and a sense that they are valued by their loved ones and society at large.

It is true that the elderly needs greater appreciation of their own diminishing dignity, their changing values and their sense of retreating worth and belonging. Although frequently forgotten, they also need some degree of freedom to choose their lifestyle. Then there is that growing sense of meaninglessness, loss of purpose for living and that underlying if pervasive personal alienation.

It is hard to help them redefine their lives with meaning, as these expressions become increasingly circumscribed because of physical or mental limitations. Also the desire for continued independence will become more and more challenging and this change can be terribly frightening and destabilising to one's psyche and self-worth. Wasn't it Truman Capote who reminded us that "Life is a moderately good play with a badly written third act."

"When I can look Life in the eyes,
Grown calm and very coldly wise,

Life will have given me the Truth,

And taken in exchange - my youth."

~Sara Teasdale
I've always maintained that Asian cultural practices imply and mandate that ageing parents should preferably be taken care of by their children. The extended family of yesteryears still conjures up in me, that wholesome if archaic sense of belonging and camaraderie which only genetically-linked kins can grasp and understand—perhaps a legacy of our selfish gene or our ingrained Confucian ethic... But increasingly, this is getting harder to comply with.

Which child among the current standard of smaller family units should or could adopt the arguably arduous task of fostering and caring of the parents? Is this always possible? Would financial or social considerations/obligations make it more difficult to expect of struggling children and their own nuclear families, to accede to this challenge, this extended role?

Would the role of nursing homes loom larger in this changing day and age, as we grapple with our own harried, time-pressured lives, our children's endless activities, our parochial self-interests? Do we still have time and space for our parents, do we wish to make time for them? Or are we past that phase of communication with a bygone generation, whose time has irrecoverably elapsed—that we have moved on to newer stuff, spanking new gizmos, adult toys, games and lifestyles, new friends, new quid pro quo acquaintances, which leave us simply no slots, no moments, for the obsolete, the superannuated, the defunct...?

Are we utilitarian pragmatists who simply move along in this interminable train of successive extensions of our DNA pool, superseding and replacing one generation after another, in an endless cycle of renewal and obsolescence?

Or do we hopelessly cling on to our humanness, our human touch of grace and virtue, of unconditional benevolence, love and agape? I'm always the optimist and the positivist, I'd elect for being the sensitive compassionate human, fully in touch with his roots and his origin...

I choose to believe in the continued dignity and integrity of the human form, with all its foibles, its ailments, its inevitable decay, and its less than perfect manifestations. As a physician, I believe it is my duty, my responsibility to alleviate suffering, extend life and protect its frequently tested dignity, from the least of disabilities to its most extreme or severe of debilitating ailments...

Our elderly citizens including our own parents must remain our most engaging if challenging experience. By being more focused, thoughtful and attentive, I know we can find our own humanity, our more aesthetic sensitivity to life: to our joie de vivre, to our woeful but heart-felt insight-generating melancholia, to self-actualise our soul...

“To resist the frigidity of old age one must combine the body, the mind and the heart - and to keep them in parallel vigor one must exercise, study and love.”
Karl von Bonstetten
"It is autumn; not without
But within me is the cold.
Youth and spring are all about;
It is I that have grown old."
~Henry Wadsworth Longfellow, "Autumn Within"

"An aged man is but a paltry thing,
A tattered coat upon a stick, unless
Soul clasp its hands and sing, and louder sing
For every tatter in its mortal dress."
~William Butler Yeats, Sailing to Byzantium

"The paired butterflies are already yellow with August
Over the grass in the West garden;
They hurt me. I grow older."
~Li Po

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