How I Taught My 95-Year-Old Mother to Make and Receive Video Calls--Most of the Time

My 95-year-old mother has been using a computer for email since our then teenage son arranged to gift her his old computer so he could get a new one. That was 25 years ago. But like most people in her age cohort, she has never been comfortable with the technology and has trouble learning anything new related to the computer. The difficulty has gotten worse over time along with her memory. But when Covid hit and visits to the independent living complex where she lives were restricted and then eliminated, the limitations of a landline telephone became all too evident. If my mother could make and/or receive video calls, she could communicate with me, with her three grandsons in California, and with friends. But using the video technology proved to be an endless source of frustration. We tried FaceTime, we tried Skype, we tried Zoom. Nothing worked. 

Now, after months of trial and error and refining the approach, I’m pleased to report that my mother can receive—and sometimes initiate—FaceTime calls. I’m so pleased that I’m going to use this blog post to describe in as much detail as I can recall every step necessary to accomplish this feat, suspecting as I do that others may find themselves in a similar predicament.

                                                Happy geriatric iPad user 

                                                (not my mother)

Step 1: Choose an appropriate device. I purchased my mother a new 10.2 inch, 32GB iPad. It’s portable, so she can use it while sitting in her favorite recliner. The screen is big enough so that people’s faces appear almost life-size and photographs are easy to see. In principle, Apple products are user-friendly, though as it turned out, my mother is a genius at outwitting the human-computer interface gurus at Apple by coming up with ways to make the system fail. Nonetheless, I think the iPad was probably as good a choice as any and better than some. The rest of the steps below apply primarily to an iPad.

Step 2: Obtain a cover that automatically turns the device off when it is closed and turns the device on when it is opened. Turning the iPad on manually was an unnecessary obstacle.

Step 3: Disable password protection for turning the device on. This may be a bit risky, but my mother was having trouble remembering her password. I “enrolled” her in touch ID, but she usually managed to put her finger in not quite the right place, so it did not work reliably. Nothing is more frustrating than being unable to even turn the thing on.

Step 4: Go to Settings, Accessibility, Assistive Touch. This setting allows my mother to use the iPad even though she has poor fine motor control and touches the screen erratically.

Step 5: Label the home button. I stuck an arrow on either side of the home button to help my mother find it. The device is designed with a very slight indentation signaling the home button, so slight that it’s hard for 95-year-old eyes to see. ➡️ ⏺ ⬅️

Step 6: Make sure Siri is disabled. I initially thought it would be easiest if my mother used Siri to make calls, simply saying “hey Siri, call Muriel Facetime video.” Wrong. She would leave out “FaceTime” or leave out “video” or forget to start with “hey Siri.” She felt compelled to speak in grammatically correct sentences, as though Siri would understand her better that way. When I left Siri enabled, just in case things changed, I found that my mother would sometimes hold the home button down too long and inadvertently invoke Siri, who would helpfully inquire “may I help you?” Having her device suddenly speak really rattled my mother.

Step 7: Put only the most essential icons in the dock. For my mother, this includes the icon for her email, Safari, and for FaceTime video. I’ve recently added the photos icon.

Step 8: Declutter the screen by putting as many of the obligatory icons, the ones you can’t get rid of, on the next screen, not the screen that is opened when the device turns on.

Step 9: Put the handful of phone numbers (with associated names) that are most likely to be used in the FaceTime contacts screen. This way, when my mother taps on the video icon, she will see 4 or 5 names and can choose which one she wants to call. Sometimes she taps on the wrong spot and calls the wrong person, but at least she’s not accidentally going to call Social Security or the Boston Globe, just a different family member from the person she intended.

Step 10: Practice! When visiting my mother, I would get her settled in her recliner with the iPad and call her from another room. For a while she had trouble with the command “slide to answer.” I finally figured out that she was carefully sliding her finger along the words “slide to answer” and assiduously avoiding the green virtual button to the left of the words. Unless she accidentally touched the button, she failed to answer the call. Now I regularly remind her that she needs to slide the button and it works like a charm. Another aspect of practicing is using the system regularly. At one point, my mother was doing great and then we didn’t make any video calls for a few days, by which time she had forgotten about sliding the button rather than the words. Making or receiving a call once a day is probably a good idea.

Sounds simple, doesn’t it? Since it literally took me months to figure this out, I thought I’d pass along what I learned, in case these steps can help someone else.

 

 

Now Hear This

Kaiser Health News—which by the way has some of the most interesting and important articles relevant to the older population in its “aging” section, and additional interesting and important articles in its “Medicare” section—ran an encouraging piece this week about hearing aids. I blogged about hearing aids almost exactly a year ago, when the President’s Council of Advisors on Science and Technology (PCAST) issued a report recommending, among other approaches, deregulating over the counter hearing aids. It looks as though this may actually become a reality.

The concern, as with OTC medications, is that the products available without a prescription will be ineffective, if effective that they will be misused, and if misused that they will lead to the substitution of bad technology for good technology. But the smart phone, smart machine era has ushered in the possibility that people could select a high quality device for themselves without a physician or audiologist as an intermediary. It may soon be possible to connect a device inconspicuously inserted into the ear to a tablet, smart phone, or television. The device may communicate directly with a digital assistant such as Siri or Alexa. And consumers may be able to test their own hearing and determine just what kind of device would serve them best using a cell phone app or online program.

There’s much yet to figure out as the boundary between personal sound amplification devices (unregulated) and hearing aids (regulated) becomes increasingly fuzzy. Standards governing their design are in the works. But Senators Charles Grassley (R) and Elizabeth Warren (D) are planning to introduce a bill soon that would allow the sale of OTC devices. How very fitting: a bipartisan effort to allow us to hear each other better.

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They All Add Up

With so much attention rightfully devoted to big ticket items in medicine such as the new drug for hepatitis C that costs $1000 a pill or high tech devices such as the continuous flow left ventricular assist device, which costs on average about $200,000 to insert, not many people are talking about the little ticket items. But the reality is that spending a small amount per person on a huge number of people adds up to just as much—or maybe more—than spending an enormous amount  per person for just a few individuals. So I was very pleased to see a research letter in JAMA Internal Medicine about that lowly test, the urinalysis. 

I was pleased that the authors looked at the consequences of the rampant ordering of urine tests in people with no symptoms suggestive of either an infection in the bladder or kidneys or acute kidney dysfunction, the only circumstances in which urinalyses have been found to be meaningful. The reason, quite simply, that most urine tests are useless or, as the article suggests, actually harmful, is that the majority of older people have bacteria in their urine. What this means is that the injudicious ordering of a urine test will far more often produce a “false positive” result than a “true positive.”

It so happens that twice in one morning of seeing patients this week, I was asked to order a urine test for no good reason. To be fair, the well-meaning daughters of the patients who requested the test, quite insistently, I might add, thought it was with good reason. Their mothers were being diagnosed with dementia, a condition that had developed insidiously over a period of at least a year and probably several, and they were hoping I would identify a “reversible cause” of this otherwise progressive, ultimately fatal illness. Neither patient, however, had any symptoms to suggest a bladder infection: they did not have burning on urination, they did not have urinary frequency, they had no fever or flank pain. One lady was 96; the other was 91. Since the majority of elderly women have bacteria in their urine, I was concerned that if we got a sample from these two (no mean feat if we wanted a “clean catch” specimen, uncontaminated by bacteria from the surrounding skin and from stool), it would show bacteria. But if we did anything with the result—and what was the point of getting the test unless we were planning to treat the ladies in the vain hope that a course of antibiotics would cure their dementia—we would do little more than expose them to a risk of another problem such as clostridium difficile colitis, a potentially serious, occasionally lethal infection common in debilitated older people that typically results from killing off other bowel bacteria with antibiotics.

So what did the new study find? The authors looked at 403 consecutive adult patients admitted to the general medical service of a hospital in 2014 and 2015. They found that in this group, who somewhat surprisingly had a median age of 79, 62% had a screening urinalysis at the time of admission. Fully 84% of these individuals lacked any symptoms suggestive of a urinary tract infection. Of the asymptomatic patients who were screened with a urinalysis, 30% had a positive test. Of those with a positive test, 22% were treated with antibiotics.

Maybe this is actually reassuring: only 30% of asymptomatic patients had bacteria in their urine, not the 90% the authors quote from the literature. And only 22% of the asymptomatic patients with a positive test were given antibiotics, not everyone. 

The research letter in JAMA Internal Medicine leaves many questions unanswered. We don’t know why so many asymptomatic patients had a urine test ordered—perhaps the physicians believed that the fall or fainting episode that triggered the hospitalization was in fact caused by a bladder infection, which is conceivable, even if dementia (what my patients suffered from) is not. We don’t know what proportion of those who were needlessly treated developed complications because of the antibiotics they received. We can’t measure just how much the injudicious use of antibiotics in situations such as this contributes to the development of bacteria that are resistant to multiple antibiotics, bacteria that go on to cause real disease that is phenomenally difficult to treat. 

We do know that there are over half a million people age 65 and over hospitalized each year according to the National Hospital Discharge Survey. If over half of them have an unnecessary test, and if a third of those tests are positive, and a fifth of those positive tests lead to potentially risky treatment, that’s still a lot of bad decisions. All those small ticket items add up, and we need to pay attention to the little decisions we make every day, not just to the big decisions we make once in a while.

Shocking News

Much has been written lately about over-treatment of older patients. Only rarely does anyone suggest that older patients are getting too little treatment, but a new study in JAMA does just that. The reality isn't quite so clear.

The treatment is the implantable cardioverter defibrillator (ICD) and the patients are people over the age of 65 who have had a heart attack and are found afterwards to have a weak heart (defined as an ejection fraction less or equal to 35%). These patients are at risk of sudden death, of an irregular heart rhythm such as ventricular tachycardia, and the ICD is designed to deliver an electric shock if that happens, effectively bringing the patients back from death. By looking at the National Cardiovascular Data Registry, which keeps track of heart attack patients, the authors of the article found that only 8.1% of “eligible” patients actually received an ICD. As a result, they claim, the 92% of patients who didn’t get an ICD were more likely to die than their counterparts who did.

This is a surprising finding in light of the persuasive and cogent argument made by Sharon Kaufman in her recent book, Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where To Draw The Line. Kaufman makes the case that many high tech treatments come to be seen by physicians and patients as normal and necessary once Medicare agrees to pay for them. The end result for many marginally beneficial, burdensome, and expensive treatments, including the ICD, is that patients just can’t say no. If that's true, why are so few older people getting an ICD? 

Now it wouldn't be the first time that ageism or misinformation prevented older people from getting beneficial treatment. Many years ago, patients who were over a certain age were precluded from receiving clot-busting drugs (thrombolytic therapy) because it was widely assumed that in older age groups, the risks outweighed the benefits. It turned out that clot-busting drugs were actually more beneficial in older patients, basically because their heart disease tended to be severe which meant they stood to gain a great deal from treatment. Elevated systolic blood pressure was likewise once assumed to be normal in the geriatric population, or even desirable in order to improve blood flow to the brain. Studies eventually showed that elevated systolic blood pressure, even in older patients, predisposed to stroke and other unfortunate outcomes, and warranted treatment—though the recommendations about just how much blood pressure should be lowered have evolved over time. Is the ICD implantation rate just another case of bias or ignorance at work?

Dr. Robert Hauser of the Minnesota Heart Institute, writing an editorial published alongside this article, blames our fragmented health care system. He speculates that primary care physicians may not realize that their patients were supposed to get an ICD. The fact that there's supposed to be a 40-day waiting period between the onset of the heart attack and implantation of the ICD contributes to the problem. Hauser suggests that the primary care physician is so frazzled and overburdened that he is apt to neglect to send his patient to a cardiologist. Is this the explanation?

It can’t be the whole story. While patients who saw a cardiologist after hospital discharge were more likely to wind up with an ICD than patients who didn’t, only 30% of the patients who saw a cardiologist had an ICD implanted. Recall that 100% of them were, technically speaking, “candidates” for an ICD. So what else is going on?

Hauser hints at another explanation: “It is possible that some older patients may refuse ICD treatment for personal reasons or because comorbidities such as endstage kidney disease or advanced frailty were considered in the decision regarding ICD implantation.” He doesn't accept this explanation as sufficient, rightly recognizing that patients are very likely to accept whatever technological intervention their physician recommends and that shared decision-making, if it takes place at all, is apt to reflect the physician’s preferences as well as the patient’s. So the problem, if it is a problem, must lie with doctors, too. Physicians are not systematically and emphatically recommending ICD implantation to their older patients. Even the most technologically sophisticated academic medical centers only implanted ICDs in 16% of their eligible older patients. But is this a problem that needs fixing, like under-treatment of heart attacks with clot busters and inadequate treatment of high blood pressure in the past?

Dr.  Hauser believes it is, saying “even though the use of ICD for primary prevention may not seem to make as much sense for an 80 year old patient as it does for a patient in his 50s or 60s, an older patient at risk for sudden cardiac death should have the same opportunity to choose potentially lifesaving therapy.” But the benefits of ICD in those over 80 are far from clear. The studies include very few people in this age group. What data there is indicates that there is little if any survival benefit. Moreover, ICDs implanted in older people fire erroneously half the time. That means they deliver a very unpleasant electric shock to the hapless patient. In addition, if the ICD does work as intended, what that means is the abolition of sudden death. 

Maybe, just maybe, the low rate of ICD implantation in older people is a refreshing instance of massive civil disobedience—of both patients and doctors refusing to abide by prevailing clinical guidelines. We all have to die of something. An ICD virtually guarantees that the something will involve a protracted period of decline and suffering. If you had to choose between cancer, Alzheimer’s disease, and sudden death, which would you pick?

The Age-Cost Connection

It’s been well known for a long time that the amount Medicare spends on patient care every year increases with age. That’s not entirely surprising—after all, 80-year-olds are in general less healthy than 70-year-olds, so they need and receive more medical care. But is there an age when per capita spending stops going up, or even falls? If you think there is, guess what age that happens. Why? What would cause spending to level off? A recent article in Health Affairs gives some of the answers, at least about the facts.

Examining Medicare data from 2000 to 2011 for fee-for-service beneficiaries, the authors confirm that as recently as 2011, Medicare per capita spending rose with age, peaking at age 96 and then gradually declining. Spending for 96-year-olds averaged $15,145 compared to less than half that, or $7566, for 70-year-olds. What’s really fascinating is that in 2000, the age at which Medicare per capita spending peaked was 92, and it’s been steadily increasing ever since.

Before we can speculate about why, we need to understand what the money is being spent on. The study answers this question as well. For nonagenarians, much of the spending goes to skilled nursing facilities (that doesn’t mean long stay nursing homes, which aren’t covered by Medicare, but rather short term, post-acute or rehabilitative care). This finding doesn’t imply that hospital spending goes down; on the contrary, spending on inpatient hospital services remains a relatively constant share of per capita spending until patients reach their late 90s.

Translation: older people use a lot of medical services. They use more and more until they are close to 100 and that includes hospital care, along with hospice and skilled nursing facility care. Evidently our view of what constitutes reasonably treatment has been shifting over time—we used to think that it was all right to treat octogenerians aggressively, but we drew the line at nonagenerians. Now we’re treating nonagenarians aggressively and drawing the line at centenarians.

There is one bit of promising news, one hint that at least some patients and doctors are thinking twice about subjecting the oldest and frailest to all the technology we can muster. If we look at per capita spending the year people die, we find that Medicare spent $43,000 on 70-year-olds but only $20,000 on centenarians. The difference was due almost entirely to a disparity in hospital use. Apparently, it’s easier to recognize or perhaps to accept that a 100-year-old is dying, and to tailor treatment accordingly, than to accept that a 70- or even a 90-year-old is dying. But once we do acknowledge the inevitable, we restrain our impulse to try to prolong life, whatever the cost both to individual dignity and to the nation’s pocketbook.

Maybe, just maybe, we will come to accept that there is a price to pay for invasive treatment even when death is not quite so imminent, and that a different kind of treatment may be more humane for those who are physically frail or demented, regardless of age.