Age and Heat-Related Disability

Abstract: This study examines how functional disability worsens among older adults exposed to extreme heat, particularly those socially isolated. Analyzing data from over 35,000 older adults aged 50 or older from the Health and Retirement Study from 1996-2018, this study found that more frequent exposure to extreme heat is associated with an increase in the number of instrumental activities of daily living (IADL) that older adults find difficulty in performing over time. 

 

This heat-related disability progression is greater among those living alone and not working. However, findings indicate that maintaining contact with children and receiving higher levels of support from friends can alleviate the risk of IADL disability progression amidst extreme heat days for older adults with limited social relationships at home and work. By examining various aspects of social isolation and their nuanced effects, this study underscores the need for social support and assistance for older adults during extreme heat. (Hyunjung et al., 2024)

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- Hyunjung Ji, Su Hyun Shin, Alexandria Coronado 1, Hee Yun Lee (2024).Extreme Heat, Functional Disability, and Social Isolation: Risk Disparity Among Older Adults. Journal of Applied Gerontology, link
- photograph by Flip Schulke (1930-2008) via

Dementia in Transgender Population: Case Vignette

In their paper, Beehuspoteea and Badrakalimuthu (2021) shortly discuss the lack of research on dementia in the transgender population and the specific need for carers to be provided with the psychoeducation necessary to better understand the impact dementia possibly has on transgender persons. They also mention the higher level of stress carers of transgender people might experience and the higher level of stress transgender persons might have when developing dementia. In order to illustrate the complexity of this intersection, the authors present a case vignette:

"A 76-year-old female transgender person was diagnosed with Alzheimer's dementia in 2014 with MOCA (MOntreal Cognitive Assessment) score of 17/30. She was treated with donepezil 10mg OD and prescribed mirtazapine 15mg ON to treat insomnia and low mood. She underwent male to female gender reassignment surgery, including bilateral breast surgery completed in 1960s, and hormonal treatment with estradiol. She considered her sexual orientation to be towards the same sex, and she was in a long-term relationship with a female partner. Her medical history included migraine and she was on propranolol 80mg OD. There was no other significant psychiatric history. She resided in her own flat and her partner lived in a separate flat in the same block. The couple had two of three surviving adopted daughters, both in their forties. The patient's primary carer was her partner and there was no formal care input. In 2016, her MOCA score dropped to 11/30 and she had impaired hygiene and nutrition. In 2018, she started wandering and bringing men to her flat and engaging with them in sexual activities leading to a high risk of vulnerability to abuse culminating in Mental Health Act assessment and admission to a dementia unit. MOCA was not performed due to receptive and expressive dysphasia. In the unit, she presented with insomnia, agitation, dysphasia, having sexually inappropriate conversations with staff about being interested in men, which was a continuation of new behaviour that was identified in the community, as well as making innuendos to female members of staff while talking about herself as a ‘man’. She presented with toileting behaviour that would identify her as male gender, for example standing to urinate as if using a urinal, interpreted as reversal towards biological gender identification. Her partner felt devastated by behaviours exhibited by the patient, which could be identified as male-gender based behaviour aligned with biological gender by birth."

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- Nirja Beehuspoteea & Vellingiri Raja Badrakalimuthu (2021). Dementia in transgender population: case vignette. Progress in Neurology and Psychiatry, link
- photograph by Lissa Rivera via

Can I Keep My Job? Adult Children Caring for their Elderly Parents

In the 1970s, studies started showing to what extent public services can support parents when it comes to combining caring for their children with participation in employment. Only in the 1990s did researchers begin to focus on the impact adult children's caring for their elderly parents can have on their participation in the labour market. According to research, the need (or wish) to care for older parents can lead to adult children losing their jobs, more absence from work, increased use of part-time work or more difficulty concentrating at work (due to being worried) and negative effects on productivity, promotion and salary.

Adult children are important care providers, most of the non-professional care is provided by daughters of older people. In other words, a great many women "in their fifties and sixties are now both working and having to care for their parents", hence "more likely than men to withdraw completely from the labour market" or work fewer hours - either because they need the time to care for the parent(s) or because of health problems resulting from attempts to combine care work with job. "Public expenditures on eldercare appear to affect both intergenerational support and female labour market participation."

Gautun and Brett (2017) investigated the connection between adult children's attendance at work and public care services for older people. 

We test the hypothesis that the detrimental effect on attendance at work of having an older parent in need of care is moderated (reduced) by the parent’s use of a public nursing homes, possibly also by home care services.

The study was carried out in Norway (n = 529, employees aged 45 to 65). A majority of respondents (80%) had provided support to their parent(s) in mostly practical form, e.g. purchases or transportation. 16% ha given nursing assistance. 58% of those reporting to have helped their parent(s) during the past year said that it was difficult to combine care and work. 

The results are interesting and probably not extremely surprising:

Institutional care for older people in need of care (i.e. nursing homes) was associated with improved work attendance among their children—their daughters in particular. Data also indicated a moderating effect: the link between the parents’ reduced health and reduced work attendance among the children was weaker if the parent lived in a nursing home. However, the results were very different for home-based care: data indicated no positive effects on adult children’s work attendance when parents received non-institutionalised care of this kind. Overall, the results suggest that extending public care service to older people can improve their children’s ability to combine work with care for parents. However, this effect seems to require the high level of care commonly provided by nursing homes. Thus, the current trend towards de-institutionalising care in Europe (and Norway in particular) might hamper work attendance among care-giving adult children, women in particular. Home care services to older people probably need to be extended if they are intended as a real alternative to institutional care.

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- Gautun, H. & Brett, C. (2017). Caring too much? Lack of public services to older people reduces attendance at work among their children. European Journal of Ageing, 14, 155-166,, link
- photograph by Dorothea Lange (1938) via

The Mortality Impact of Heat Waves on Different Age Groups

Heatwaves in Europe, becoming more and more common, have a disproportionate impact on older people. In 2021, 90% of heat-related deaths in the United Kingdom were among people aged 65 and older. When France had its deadliest heatwave in 2003, most of the 150,000 people who died were older (via). 

Masselot et al. (2023) analysed data of 854 European cities from thirty countries (27 EU, Norway, Switherland, UK) with more than 50,000 inhabitants to study the mortality impact of high temperatures on different age groups.. Average temperature-related mortality relative risks (RR) showed an increasing trend by age. The city with the highest heat-related mortality risks was Paris - across all ages and for the age group 85 and older in particular. Generally, effects were larger for the oldest age group with three to four excess deaths due to heat per 100,000 person-years (38% of the total burden for heat). In contrast, there was less than one per 100,000 person-years in the youngest age group. Overall, i.e., considering heat and cold, those aged older than 85 contributed about 40% of the total mortality burden. 

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- Pierre Masselot, Malcolm Mistry, Jacopo Vanoli, MSc Rochelle Schneider, Tamara Iungman,  David Garcia-Leon,  Juan-Carlos Ciscar,  Luc Feyen,  Hans Orru,  Aleš Urban,  Susanne Breitner Veronika Huber,  Alexandra Schneider,  Evangelia Samoli,  Massimo Stafoggia,  Francesca de’Donato,  Shilpa Rao,  Ben Armstrong,  Mark Nieuwenhuijsen,  Ana Maria Vicedo-Cabrera,  Antonio Gasparrini (2023). Excess mortality attributed to heat and cold: a health impact assessment study in 854 cities in Europe. The Lancet, 7(4), 271-281, link
- photograph by Martin Parr via

Days With My Father. By Phillip Toledano.

"My Mum died suddenly on September 4th, 2006 After she died, I realized how much she’d been shielding me from my father’s mental state. He doesn’t have alzheimers, but he has no short-term memory, and is often lost. I took him to my mother’s funeral, and to the burial, but when we got home, he’d ask me every 15 minutes where my mother was. I’d explain carefully that she had died, and we’d been to her funeral. This was shocking news to him Why had no-one told him? Why hadn’t I taken him to the funeral? Why hadn’t he visited her in the hospital? He had no memory of these events. After a while, I realized I couldn’t keep telling him that his wife had died. He didn’t remember, and it was killing both of us, to re-live her death constantly. I decided to tell him she’d gone to Paris, to take care of her brother, who was sick. And that’s where she is now.

 (...) I have so many memories of him listening to opera, sketching, painting, sculpting. Although he doesn't paint anymore, he still sees. He still has the artistic impulse. (...) The urge is still there, even if the physical ability is not ...

(...) For just a few minutes, everything almost feels normal again. My mum isn't dead, and we're not pretending she's gone to Paris. She's popped out to the store, and she'll be back shortly. How sweet that would be.

(...) It's amazing. My father is so appreciative of the love he receives. Each visit is an incredible gift, to  him, and to me, as though we're both drinking deeply from the same well, for one last time. He's always talking about how much he loves me. What a genius he thinks I am. How glad he is that Carla is part of our (tiny) family. These are things he's never told me before. I'm so glad we have this time together.

(...) Sometimes when we are talking, my dad will stop and sigh, and close his eyes. It's then that I know that he knows. about my mum. About everything.

My dad died yesterday. I spent the whole night with him, holding his hand (...). Just last week, on his 99th birthday, I asked him how old he thought he was. Grinning, he said: "22 and a half?" Now he's gone to Paris, to meet my mum."

Philipp Toledano

photographs by Philipp Toledano via

Abendlied. By Birthe Piontek.

I worked on the series for about seven years – from 2011 until 2018. In the first two years, I wasn’t sure what I was doing; little was I aware that the project might end up in a book. I just had the urge to express what I saw and felt when I visited my family in Germany. It was the time where my mother showed the first signs of Dementia; however, we weren’t sure about that back then, or better: we were in denial. 

But something was shifting; she was slowly slipping away, and so was the house I grew up in. After two years of working on the project, I found that I had started to develop a visual language for what was going on, and I also knew what I wanted to say. However, like with any project, it takes a lot of trial and error and a lot of time to refine ideas and images. It was especially challenging as I wasn’t physically present on an ongoing basis and only had a few weeks each year to work on it. But in many ways, the breaks were also useful to digest what I worked on and let ideas simmer.

(...) For a long time, while working on the series, I was afraid that this might not be the case, that the images would be “too personal” and the viewer wouldn’t be able to access it. I think, as much as this project is a personal one, it is also very universal. In many ways, the materials I’m working with are universal, too, even though they might have a specific meaning for my family. But the viewer knows what these materials are. One knows about the symbolic meaning of collected teeth, hair, or precious porcelain. We all have versions of these mementos in our homes. And, at some point in our lives, we all encounter losses and the accompanying grief. We understand the power and workings of change and we understand when something comes to an end. Maybe, it’s not so much the materials, but the universality of these experiences that make it possible for the viewer to enter the work – and feel it.

Birthe Piontek

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photographs by Birthe Piontek via and via and via and via and via

Women and Smoking Stigma in South Korea

Generally speaking, fewer women smoke than men. There are however, cultural and regional variations and greater gender differences are found in South Korea, Indonesia, and China, compared to Europe and the United States. South Korea, for instance, has the highest male smoking rate and the lowest female smoking rate of all (OECD) countries (Park et al., 2014). The World Health Organization (2017) estimates that 40% to 50% of men and 4% to 8% of women in Korea smoke; according to the OECD (2015) it is 31.3& of males and 3.4% of females (Gunter et al., 2020). Gender is a factor.

Women may encounter negative social attitudes toward women's smoking. This stigma can have an impact on their smoking cessation motivation and concealment (David et al., 2024). Korean women, for instance, underreport their smoking activity because of the stigmatisation. This stigma may prevent many Korean woman from smoking (Woo, 2018). Using biological indicators (urinary cotitine concentration), others come to the conclusion that the "actual female smoking rate is significantly highere than official records state" and that the social desirability bias produces results that underestimate the number of female smokers (Park et al., 2014).

This study shows that the actual female smoking rate is significantly higher than that reported officially, but also that the gap is decreasing steadily. Females exhibited a higher rate of false responses, which resulted in an underestimation of the female smoking rate. (Park et al., 2014)

Concealment is not really surprising given harsh reactions might be possible as the following two anecdotes imply:

"I was a bit tipsy and felt like a puff. After I lit the cigarette, a random middle-aged man came up to me and started shouting as if I had done something very bad. He said, ‘I will slap your face if you don't throw your cigarette away right now.' He called me ‘dirty little woman.'" (Kim, 26)

"When I was smoking outside, an old man shouted at me how dare I, a female, smoke there. People say the social atmosphere about female smoking has changed but this kind of thing still happens. Men cannot understand how scared women get in those situations." (Lee, 33)

In South Korea, women use heated tobacco products for different reasons than men do, i.e., to avoid the stimga associated with female smoking while men use them to avoid family members putting pressure on them to stop smoking (Kwanwook et al., 2020)

As has been well-established by previous studies, the smell of cigarettes was the main reason for using HTP for both male and female users. Nevertheless, there was a gender difference in the cause for concern about the smell of cigarettes, especially regarding the person(s) to whom participants thought the smell was an issue. Males tended to identify smell as a problem when it came to their familial responsibilities with their wives and children. Many participants felt guilty for using cigarettes due to their harmfulness to health and exposing their family members to secondhand smoke. For these participants, these feelings, usually recognised, and revived by the very smell of tobacco, could be reduced through the use of HTPs with a relatively low odour. Therefore, males were more concerned with the ‘physical’ characteristics of the cigarette smell as a reminder of the harmfulness of tobacco. 

‘When I got married, my wife knew that I was a smoker and did not care too much. But when she got pregnant, she kept telling me, “Your body smells of cigarettes. Don’t come near, it’s bad for a child”. She told me a lot to stop smoking. So, I thought about various ways, and finally bought IQOS which was easily available. I think it would be better to choose one that doesn’t smell to my family.’ (Male, 39 years) 

Unlike the male participants, female participants were more interested in the ‘socio-cultural’ rather than physical characteristics of the tobacco smell. In other words, women were conscious that their tobacco smell would expose their smoking habit in a patriarchal society where female smoking is still a highly stigmatised activity, particularly in the workplace. Therefore, unlike men, they were reluctant to disclose their smoking habit. In particular, women with children were extremely vigilant about concealing such socially unacceptable behaviour as smoking, when among other parents and their children’s teachers, because of the perception that they should be a morally upright ‘agi-eomma’ (a baby’s mother). For these reasons, women chose HTPs to maintain their social status as a righteous working woman or mother.  

‘I should not let my colleagues in the company notice the smell from my smoking. Since my sister introduced me to “lil”, I have used it while working and smoked CCs at home.’ (Female, 22 years)  

‘For me, [the] IQOS has solved every interpersonal problem caused by the smelly cigarette. Now I have been able to avoid uncomfortable gazes, [I am] liberated from the smell, and [I have] improved interpersonal relationships with my children’s teachers or other parents. I used to be unable to smoke openly because I was given kind of a name tag called “agi-eomma” (a baby’s mother).’ (Female, 42 years) (Kwanwook et al., 2020)

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- David, J.-C., Fonte, D., Sutter-Dallary, A.-L., Auriacombe, M., Serre, F., Rascle, N. & Loyal, D. (2024). The stigma of smoking among women: A systematic review. Social Sciene & Medicine, 340, 116-491. Korean Journal of Family Medicine, 41(3)
- Gunter, R., Szeto, E., Jeong, S.-H., Suh, S. & Waters, A. J. (2020). Cigarette Smoking in South Korea: A Narrative Review. 
-  Kwanwook Kim, Jinyoung Kim, Hong-Jun Cho (2020). Gendered factors for heated tobacco product use: Focus group interviews with Korean adults. Tobacco Induced Diseases, 18(43), link
- Myung Bae Park, Chun-Bae Kim,corresponding author Eun Woo Nam & Kyeong Soo Hong (2014). Does South Korea have hidden female smokers: discrepancies in smoking rates between self-reports and urinary cotinine level. BMC Womens Health, 14(156), link
- Woo, C. (2018). Gendered Stigma Management among Young Adult Women Smokers in South Korea. Sociological Perspectives, 61(3), link
- photograph by Nina Ahn via

Calling the Birds Home. By Cheryle St. Onge.

My mother and I have lived side by side on the same farm for decades. Our love was mutual and constant. She developed vascular dementia, and so began the flushing away of her emotions and her memory. At first I stopped making pictures with her, then I stopped making pictures at all. 

Perhaps as a counterbalance to her conversations of why she wanted to die, of how she imagined she could die. And because I needed some happiness, some light in the afternoon, these portraits of my mother began. At first made with any camera within reach, phone-camera, or 8” x 10” view camera. Made in the moment, as a distraction from watching her fade away. I would make a picture of her, then share that picture of her with others I love. Sharing the act of being in the moment, sharing the ephemeral nature of my looking and her seeing.

x

Now, when I leave our home, when I leave my mother behind, people find me. They want to tell me their stories and they want to hear mine. It's a beautiful back and forth, much like a true portrait.. Because of the dementia, we have no conversations. But we do still have this profound exchange - the making of a portrait. 

She must recall our history and the process of picture making. Because she brightens up and is always up for what my children would refer to as the long effort with the long camera. That best describes sitting before an 8” x 10” view camera, on top of a tripod with its bellows extended out. My mother does her best and I do mine. And then in turn, I give the picture away to anyone who will look. It is an excruciating form of emotional currency.

Cheryle St. Onge

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photographs by Cheryle St. Onge via

Substance Use: Men vs Women

The American Addiction Centers point out some gender differences in connection with the consumption of illegal drugs. For instance, men are more likely to die of overdose and misuse of prescription than women. Women are more susceptible to craving and relapse. Women are also less likely to inject heroin than men and show the tendency to use smaller amounts in shorter intervals. Those women who do inject heroin, however, are more likely to additionally use prescrption drugs than men and are more at risk of dying from heroin overdose. Women also seem to begin using cocaine sooner and in larger amounts than men. 

Similarly, women start methamphetamine use earlier than men and become comparably more dependent on the substance. Fewer women than men die from prescription opioid overdoses, a trend that seems to be changing since death rates for women increased rapidly. Men are less likely to misuse prescription opioids to self-treat for reasons such as anxiety or stress while women are more likely to take them without a prescription to cope with pain. Generally, the risk of developing a substance use disorder is the same for both genders (via).

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photograph (Man in drug den, Durban, 1985) by Omar Badsha via

Age Limits for Blood Donation

The World Health Organization suggests the ideal donor be aged 18 to 65 (via). The American Association of Blood Banks used to bar peope aged over 65 (without written consent from a doctor) from donating blood. The rule was eliminated in 1978; now older people donate blood as long as they wish to and are well (via and via). In other words, healthy older people can - just like healthy younger people - "continue to safely donate and make a significant contribution to the blood supply past arbitrary age limits" (Goldman et al., 2019).

Back in 1996, Janetzko et al. examined blood donation in elderly donors and came to the conclusion that "blood donation in otherwise healthy persons aged over 65 years should be accepted". At the request of the UK Blood Services Forum, Stainsby and Butler (2008) prepared recommendations for the removal of the upper age limit based on an evaluation of available evidence of the safety of accepting blood donors beyond the age of 70. The authors concluded that "donors of whole blood and blood components can safely continue to donate beyond the age of 70, with no absolute upper age limit" if they meet the criteria needed.

In the past, there were concerns about the safety of blood donation for older donors, with upper age limits commonly applied. However, a recent comparative study using data from four countries and comparing deferral and vasovagal rates for whole-blood donation between donors aged 24-70 and 70+ concluded that age-based exclusions from donation based on safety concerns were not warranted [7]. At present, the upper age limit for blood donation differs among blood collection agencies (BCAs) worldwide. (Goldman et al., 2019)

The Bavarian Red Cross no longer has an upper age limit. Both those donating for the first time and those aged over 60 will be tested if they are suitable donators (via). The UK legislation on age limits for donors obliges regular donors to retire on reaching their 70th birthday and component donors on their 66th means discrimination. Stainsby and Butler (2008) point out that an arbitrary upper age limit is hard to justify. In fact, the National Blood Service received written complaints. Between April 2005 and March 2006, 107 complaints were received, including one from a Member of Parliament. The NHS does not accept any first-time donors over 66 and (since 1998) returning donors until they turn 70 but adds that one may continue after the age of 70 as long as one is in good health and has made at least one full donation in the past two years. On their website, the NHS points out that a review of date "suggests that it would be safe to allow older donors to continue past their seventieth birthday" (via). Still, in Italy you can only donate until the age 65 (via), in Japan until 69 (via). The Austrian Red Cross still has a general upper age limit of 70 and 60 for those donating for the first time (via). In the Netherelands, the upper age limit for blood donation was raised from 69 to 79 in 2018 (Quee et al., 2024).

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- Goldman, M., Germain, M., Grégoire, Y., Vassallo, R. (2019). Safety of blood donation by individuals over age 70 and their contribution to the blood supply in five developed countries: a BEST Collaborative group study: SAFETY OF DONATION, OLDER DONORS. Transfusion, 59(4)
- Janetzko, K., Böcher, R., Klotz, K. F., Kirchner, H. & Klüger, H. (1996). Blood donation after reaching 65 years of age. Beitr Infusionsther Transfusionsme, link
- Quee, F. A., Zeinali Lathori, A., Sijstsma, B., Brujns, S. & van den Hurk, K. (2024). Increasing the upper age limit for blood donation: Perspectives from older donors. Vox Sang., link to interesting abstract
- Stainsby, D. & Butler, M. (208). Recommendations for removal of the upper age limit for regular whole blood and component donors. 
- photograph (of Eggleston's grandmother Minnie Maude Mae at her home in Mississippi, 1970-1973) by William Eggleston via

"Early in the morning, there's tolerance and later in the day it disappears." On Stress and Stigma.

Abstract: Stress is a challenge among non-specialist health workers worldwide, particularly in low-resource settings. Understanding and targeting stress is critical for supporting non-specialists and their patients, as stress negatively affects patient care. Further, stigma toward mental health and substance use conditions also impacts patient care. However, there is little information on the intersection of these factors. This sub-analysis aims to explore how substance use and mental health stigma intersect with provider stress and resource constraints to influence the care of people with HIV/TB. 

We conducted semi-structured interviews (N=30) with patients (n=15) and providers (n=15, non-specialist health workers) within a low-resource community in Cape Town, South Africa. Data were analyzed using thematic analysis. Three key themes were identified: (1) resource constraints negatively affect patient care and contribute to non-specialist stress; (2) in the context of stress, non-specialists are hesitant to work with patients with mental health or substance use concerns, who they view as more demanding and (3) stress contributes to provider stigma, which negatively impacts patient care. Findings highlight the need for multilevel interventions targeting both provider stress and stigma toward people with mental health and substance use concerns, especially within the context of non-specialist-delivered mental health services in low-resource settings. (Hines et al., 2024)

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- Hines, A. C., Rose, A. L., Regenauer, K. S., Brown, I., Johnson, K., Bonumwezi, J., Ndamase, S., Ciya, N., Magidson, J. F. & Myers, B. (2024). "Early in the morning, there's tolerance and lter in the day it disappears" - The intersection of resource scarcity, stress and stigma in mental health and substance use care in South Africa. Cambridge Prisms: Global Mental Health, link

- photograph by Santu Mofokeng via

Excluding Elderly People from Clinical Trials

The elderly make up "the lion's share of patients for certain health conditions" and the majority of patients for many conditions that need medications. At the same time, clinical trials in adult populations usually include patients ranging from the age of 18 to only 64. Due to the arbitrary upper age limits, elderly patients are often not represented in clinical trials resulting in little knowledge about their responses to medications. In fact, up to 35% of published trials exclude older people (Shency & Harugeri, 2015)

Although persons aged ≥65 years represent only about 13% of the population, they consume nearly one-third of all medications. (Shency & Harugeri, 2015)

Further research indicates that older adults carry 60% of the national disease burden but represent only 32% of patients in phase II and III clinical trials. (Herrera et al., 2010)

Age-related changes do have an impact on how an organism responds to pharmacological interventions. These changes can, for instance, be related to hepatic and renal functions (which affect e.g. the absorption and excretion of the drugs), the decrease of gastric acid secretion with ageing,, slowing of gastric emptying, diminished gastrointestinal blood flow, the decrease in albuin (which increases concentrations of many drugs), decrease in body water, increased sensitivity to antipsychotic drugs (due to an increase in monoamine oxidase activity), brain atrophy, reduction in cerebral blood flow, loss of cholinergic neurons (hence more sensitivity to drugs that have anticholinergic effects), impaired metabolism etc. (Shency & Harugeri, 2015).

Hence, age-dependent decrease in total clearance is expected for drugs that are eliminated by kidneys. The use of standard doses of these drugs may result in increased plasma concentration and increased risk of adverse drug reactions in elderly.

It has been found that the elderly are underrepresented in cancer clinical trials, more pronounced in trials for early-stage cancers than in trials for late-stage cancers.

In USA, though the elderly aged ≥65 years account for 61% of all new cancer cases and 70% of all cancer deaths, in the clinical trials active between 1993 and 1996, the elderly comprised only 25% of oncology trial participants.[11] A study audited 226 clinical research proposals recording exclusion of patients based on an arbitrary upper age limit and found that significant proportion (13.7%) of clinical trials excluded patients based arbitrarily on an upper age limit.[12] However, none (9.8%) of the trials submitted by geriatricians excluded patients based solely on age. The mean upper age limit used over all trials as a cut-off was 69.2 years. Over 50% trials submitted by neurology/psychiatry excluded patients based on an upper age limit.[12]

Although elderly patients represent the majority of the heart failure (HF) population, and have a worse prognosis compared to younger cohort commonly included in trials, targeted treatment strategies have been insufficiently developed for them. (...)

A 7 years review of elderly patients’ enrollment in cancer drug registrations by U.S. Food and Drug Administration (USFDA) found statistically significant under-representation of the elderly.[16] (Shency & Harugeri, 2015)

Not only are older people underrepresented when it comes to cancer, cardiovascular disease or epilepsy but, most absurdly, clinical trial participation of older people is also ridiculously low in research on Alzheimer's disease, arthritis and incontinence (Herrera et al., 2010).

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- Herrera, A. P., Snipes, S. A., King, D. W., Torres-Vigil, I., goldberg, D. S. & Weinberg, A. D.  (2010). Disparate Inclusion of Older Adults in Clinical Trials: Priorities and Opportunities for Policy and Practice Change. American Journal of Public Health, 100(1), 105-112.
- Shency, P. & Harugeri, A. (2015). Elderly patients' participation in clinical trials. Perspectives in Clinical Research, 6(4), 184-189, link
- photograph by Diane Arbus via

Ageism in Marriage and Family Therapy

Abstract: The paucity of literature addressing mental health issues concerning geriatric populations represents the perpetuation of ageist practices and beliefs in the field of marriage and family therapy. The purpose of this study was to assess whether client age and clinical training relate to the evaluation of couples who present for conjoint therapy. Written vignettes describing two couples, one older and one younger, who report issues involving the absence of sexual intimacy, increased frequency of arguments, and increased use of alcohol were evaluated by practicing marriage and family therapists, therapists-in-training, and individuals with no clinical background. 

It was hypothesized that respondents' views would vary in connection with the age of the couple and with the three levels of participant training. Results indicate that client age and participant training are associated with perceptions of individual and couple functioning. Our findings suggest that the relational and mental health concerns experienced by elder couples are not perceived as seriously as are identical concerns experienced by younger couples. Contrary to our expectations the observed differences between views of the two age conditions did not significantly differ between levels of participant training. Training and experience in marriage and family therapy may not significantly mitigate vulnerability to age-discrepant views. (Ivey, Wieling & Harris, 2000)

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- Ivey, D. C., Wieling, E. & Harris, S. M. (2000). Save the Young - the Elderly Have Lived Their Lives: Ageism in Marriage and Family Therapy. Family Process, 39(2), 163-175.
- photograph by Gabriele and Helmuth Nothelfer via

Personality Disorders, Eccentricities or Ageism?

Abstract: Personality disorders, especially in older adults, are among the most difficult psychiatric disorders for nurses to assess. When aging further complicates these disorders, nurses' therapeutic skills are challenged. It has long been thought that personality disorders "age out," but new research indicates that personality disorders may in fact continue throughout the life span. 

 

In addition, the primary and secondary changes of aging further complicate assessment. Assessment of personality disorders in older adults may also be distorted by ageist stereotypes and a lack of understanding of cultural context. Likewise, nurses must be careful about misinterpreting "eccentric" older adult behavior as a personality disorder. In this article, we focus on assessment challenges in older adults to help nurses distinguish between characteristics of personality disorders, stereotypes, and eccentricities in this population. (Magoteaux & Bonnivier, 2009)

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- Magoteaux, A. L. & Bonnivier, J. F. (2009). Distinguishing between personality disorders, stereotypes, and eccentricities in older adults. Journal of Psychosocial Nursing and Mental Health Services, 47(7), 19-24, link
- photograph of Bette Davis via

Bad Blood, the Tuskegee Experiment, and a Legacy of Distrust

From 1932 until its exposure in 1972, the U.S. Public Health Service (PHS) ran "The Tuskegee Study of Untreated Syphilis in the Negro Male". Originally, it was supposed to last six months. It went on for forty years. 600 Black American men (399 men with "bad blood", i.e., latent syphilis and 201 free of the disease for the control group) were recruited in Alabama to study the progression of syphilis including recording the progress of disease until its final stage, autopsy. 

The men - poor sharecroppers who took part without informed consent - were given placebos, e.g. aspirin and mineral supplements, although penicilin was introduced in 1947 becoming the recommended treatment (via). While withholding available treatment and not disclosing the diagnoses, the PHS told them that they were receiving free therapies for "bad blood". Obviously, “the men’s status did not warrant ethical debate. They were subjects, not patients; clinical material, not sick people.” (via). There were fliers out offering free health care and free burial:

It offered the men free health care, annual checkups, certificates of appreciation and free burial. They did not tell them that they had syphilis. And one man who found out what he had drove over to Montgomery to a clinic to get treated. And the doctors had him chased and brought back and warned the clinic that if they ever treated another subject from Tuskegee, they would lose their federal funding. Jean Heller

Things started changing in 1966. Peter Buxtun, who was working as a venereal-disease investigator for the PHS (and later became one of the most important whistleblowers) heard his colleagues talking:
“I’m seated in this dinky coffee room and I hear several colleagues talking about an ill, insane man who was taken by his family to see a doctor outside of Tuskegee, Alabama. The doctor determined the man had syphilis and gave him a shot of penicillin. To everyone’s shock, however, the doctor was soon called on the carpet by physicians for the Communicable Disease Center (known today as the Centers for Disease Control) and reprimanded. They said he had ‘ruined their study’ and ‘jogged their statistics.’” 

Over the following years, Buxtun requested whatever material was available, made investigations, educated himself on the history of unethical research, tried to convince his colleagues, sent his assessment to his superiors and got lectured for doing so. The study continued. In 1972, finally, Edith Lederer, a reporter with the Associated Press, passed Buxtun's story on to her superiors which led to newspaper headlines across the country about the victims going untreated for forty years. Only then did the study stop (via and via). By that time, 28 participants had died from syphilis, 100 from related complications, at least 40 wives had been infected and the disease had been passed to 19 children at birth (via). In 1974, survivors and heirs of those who had died received a ten million dollars out-of-court settlement, in 1993 Bill Clinton officially apologised, in 2004 the last participant passed away.

An arch-conservative and proud Oregon Duck, Buxtun is a lifelong Republican, strong NRA supporter (the owner of several dozen guns), and a collector of medieval weaponry. But regardless of his political persuasion, organizational affiliations, and hobbies, Buxtun learned at an early age to consider the lives of poor, Black sharecroppers beyond what they were thought of by the medical establishment: as autopsy material. He did not need a popular movement or newspaper headlines to tell him what to do. Buxtun saw a wrong perpetrated by powerful forces and spent years trying to right it. Without his courage and perseverance there is no telling how much longer the ethically toxic Tuskegee Syphilis Study would have continued. (via)

The Tuskegee experiment was possible because of a combination of a military approach to medicine and racist ideology:

First, it is important to understand that the Public Health Service was established in the U. S. Surgeon General's office and was operated as a military organization. Amidst the development of an imperial agenda of the U.S. in the late 19th and early 20th centuries, the PHS was responsible for protecting hygiene and the superiority of "the American race" against infectious foreign elements from the borders. The U.S. Army's experience of medical experiments in colonies and abroad was imported back to the country and formed a crucial part of the attitude and philosophy on public health. Secondly, the growing influence of eugenics and racial pathology at the time reinforced discriminative views on minorities. Progressivism was realized in the form of domestic reform and imperial pursuit at the same time. Major medical journals argued that blacks were inclined to have certain defects, especially sexually transmitted diseases like syphilis, because of their prodigal behavior and lack of hygiene. This kind of racial ideas were shared by the PHS officials who were in charge of the Tuskegee Study. Lastly, the PHS officials believed in continuing the experiment regardless of various social changes. They considered that black participants were not only poor but also ignorant of and even unwilling to undergo the treatment. When the exposure of the experiment led to the Senate investigation in 1973, the participating doctors of the PHS maintained that their study offered valuable contribution to the medical research. (Park, 2017)

The Tuskegee study is far from being the only case in which Black people were exploited in the name of medicine but it has become "the" study symbolising this kind of abuse. Today, this experiment is seen as one primary driver of distrust Black communities have in the U.S. health care system. It is also used to show Black Americans why they should not cooperate with medical researchers. Still, the racism that fueled this study had existed for centuries before (via, Northington Gamble, 1993). After the Tuskegee study, the federal government strengthened regulations aiming to protect subjects of human experimentation. Despite the increased safeguards, Black Americans still fear to be abused in the name of medical research, a distrust (e.g. vaccine skepticism today) that is the direct result of "the broader history of race and American medicine". US-American medicine, in fact, supported racist social institutions and laws (Northington Gamble, 1993).

Geriatric psychiatrists are in a critical position to either heal or harm, repair or further damage, older Black Americans’ distrust of our healthcare system. Older Black patients served by geriatric psychiatry remember the painful memory of Tuskegee in their minds and bodies and pass this memory on to their families. Bearing in mind that history is our most ominous caution and our greatest teacher in understanding and hopefully ending today's healthcare injustices, what will geriatric psychiatrists do to transcend the wrongdoings of Tuskegee? (Black, Ramos & Anderson, 2022)

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- Black, C. B., Ramos, M. & Anderson, N. (2022). From "Bad Blood" to "Racial Disparities:" Will Geriatric Psychiatrists Transcend to Wrongdoings of Tuskegee? The American Journal of Geriatric Psychiatry, 30(8), link
- Northington Gamble, V. (1993). A Legacy of Distruct: African Americans and Medical Research. American Journal of Preventive Medicine, 9(6), 35-38.
- Park, J. (2017). Historical Origins of the Tuskegee Experient: The Dilemma of Public Health in the United States. Uisahak, link
- photographs of Tuskegee study subjects via and via and via and via and via 

Driving Cessation and Health Outcomes in Older Adults

Abstract: Sixteen studies met the inclusion criteria. Driving cessation was reported to be associated with declines in general health and physical, social, and cognitive function and with greater risks of admission to long-term care facilities and mortality. A meta-analysis based on pooled data from five studies examining the association between driving cessation and depression revealed that driving cessation almost doubled the risk of depressive symptoms in older adults (summary odds ratio = 1.91, 95% confidence interval = 1.61-2.27). (Chihuri et al., 2016)

- Chihuri, s., Mielenz, T. J., DiMaggio, C. J., Betz, M. E., DiGuiseppi, C., Jones, V. C. & Li, G. (2016: Driving Cessation and Health Outcomes in Older Adults, Journal of the American Geriatrics Society, link
- photograph (North Hollywood, 1970) via

Single Fathers: A Growing and Neglected Population

The number of single-parent families is rising and most of them are headed by single mothers. Nevertheless, single fathers represent a sizeable proportion and are both a growing population and largely understudied since research on single parenthood mostly focuses on single mothers, their greater risk of mortality, poorer self-rated (mental) health and lower socio-economic status. "What do we know about these fathers, and their health and wellbeing? Alarmingly, the answer is: not very much."

40.000 people (single and partnered fathers, single and parthnered mothers) took part in the Canadian Community Health Survey. Single fathers - after a median follow-up of eleven years - were more likely to die than single or partnered mothers or partnered fathers. Their mortality risk was more than two times higher than other parents'. Single fathers were also more likely to lead unhealthy lifestyles (eating fruit and vegetables, binge drinking).

Interestingly, the study could not determine the leading cause of death. This might partly be due to the fact that there are differences in the pathways leading to single parenthood. Single fathers, for instance, were more likely to be separated, divorced or widowed compared to single mothers. The latter could point to grief and a specific stress exposure. Gender stereotypes, stigma and social support usually more availabe for single mothers may be further factors. 

We need to take single fatherhood much more seriously as a public health issue. Understanding the way families have evolved and are likely to evolve is crucial to meet their needs and for policy planning. Families do not exist in a vacuum. They depend on the social and economic environments around them. Issues of isolation (real or perceived) and grief may be as important for health as traditional risk factors. We need to ensure that there is better community and social support for single fathers. Social and life circumstances of single parents are crucial to getting the fuller picture of their health. (via)        

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- Editorial (2018). Single fathers: neglected, growing, and important. The Lancet, 3(3), link

- photograph of Robert Redford with his daughter Shauna, 1969 via

The Complex Relationship between Skin Colour and Sun Sensitivity

Background: Eumelanin, the primary pigment in human epidermis, has a well-established photo-protective role. It can confer a protection factor of up to approximately 13.4 in some individuals. However, the protection eumelanin affords is not absolute and, further, the susceptibility of human skin to the harmful effects of UV radiation is more complex than skin pigmentation alone. 

Objective: Our survey explored the lifetime prevalence of sunburn in people of African Ancestry based in the UK (Black African or Black Caribbean). 

Results: A significant number of respondents, 52.2% (n=222), reported a history of sunburn. Interestingly, there was a significant increase in frequency of sunburn in those with a lighter skin tone (self-classified from dark, medium and light – 47.3%, 53.5% and 71.4%, respectively). In total 69% reported that the episode of sunburn occurred when they were not using sunscreen, and another 10% could not recall whether sunscreen was used. A large proportion of respondents (59%) indicated that they had been sunburnt while away from the UK in hot/sunny climates, raising the question of whether intermittent sun exposure at high UV indices is a key factor in sunburn risk for those living in temperate climates. 

Conclusion: Our findings do not support the hypothesis of a simplistic relationship between skin colour and sun sensitivity and encourage us to re-examine this relationship and its implications for public health promotion. It also adds to a body of evidence revealing the need for more up-to-date and appropriate systems to assess the risk UV radiation poses to diverse populations. (Bello, Sudhoff & Goon, 2021; literally)

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- Bello, O., Sudhoff, H. & Goon, P. (2021). Sunburn Prevalence is Underestimatein UK-Based People of African Ancestry. Clinical, Cosmetic and Investigational Dermatology, 14, full article: link
- photograph by Garry Winogrand via

French, Italian, Polish or German? The Othered Disease.

If a disease is repugnant, it can only be foreign. And if sex is involved, "it's always somebody else who is the dirty, rotten scoundrel", preferably the enemy (via). When, in 1494, King Charles VIII of France invaded Naples, his army collapsed within a few months, not because of the Italian army but a "mysterious new disease" that killed his soldiers or left them weak and disfigured (via). Italian doctors called it the French disease, the French called it the Neapolitan disease. As it spread, it became known as the "French disease" in Germany, Scandinavia, Spain, Iceland, Crete, and Cyprus (via).

"French soldiers spread the disease across much of Europe, and then it moved into Africa and Asia. Many called it the French disease. The French called it the Italian disease. Arabs called it the Christian disease. Today, it is called syphilis." (via)

In England and Ireland, syphilis was named after two enemies of the English crown: the French or the Spanish disease, the latter being popular in Spain's enemies, such as Portugal, the Netherlands, and North African countries, but also Denmark. In Poland, it was the German disease, in Russia it went by the Polish disease. The furher away from Europe, the more these distinctions based on hostile attitudes blurred into one. In the Ottoman Empire and on the Indian subcontinent, syphilis simply became the European or Christian disease (via).

The “French disease” as the English long called it, is an infamously “othered” illness. In 2014 academics in Bucharest traced its linguistic history and found that, even as the English used to call it the French disease, the French called it the Neapolitan one. The othering didn’t stop there. The Russians called it Polish, the Poles called it German, the Germans called it French and the Danish called it Spanish. The Turks eschewed nationalism for sectarianism, calling it the “Christian disease”, while, as the researchers observed: “in Northern India, the Muslims blamed the Hindu for the outbreak of the affliction. However, the Hindu blamed the Muslims and in the end everyone blamed the Europeans.” (via)

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image of the amazing Annie Girardot and Philippe Noiret via

Pandemic Depression + Age

Using telephone and web survey data to study the impact of social determinants and health-related factors on depressive symptoms during the initial lockdown that started in March 2020 in Canada, Raina et al. (2021) came to the conclusion that overall, older adults had "twice the odds of depressive symptoms during the pandemic compared to pre-pandemic". Further factors having an impact were. lower income, poorer health, loneliness, caregiving responsibilities, separation from family, family conflict, and gender (women were more affected).

"The COVID-19 pandemic has had a disproportionated impact on older adults, with groups of people who were already marginalized feeling a far greater negative impact." Parminder Raina

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- Raina, P., Wolfson, C., Griffith, L., Kirkland, S., McMillan, J., Basta, N. Joshi, D., Erbas-Oz, U., Sohel, N., Maimon, G., Thompson, E. &  CLSA team (2021). A longitudinal analysis of the impact of the COVID-19 pandemic on the mental health of middle-aged and older adults from the Canadian Longitudinal Study on Aging. Nature Aging, 1, 1137- 1147; link
- photograph by Harvey Stein via