Caring for 'elder orphans'; effects of loneliness; cannabis edibles: Upstate Medical University's HealthLink on Air for Sunday, Dec. 22, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a geriatrician addresses the concept of "elder orphans," who have no children to care for them as they age.

Sharon Brangman, MD: ... I also see people who have children who are either estranged or live far away, so they're not readily available to help when somebody starts to need care. ...

Host Amber Smith: A psychiatrist shares the latest research into loneliness.

Hilary Gamble, MD: ... The surgeon general reported that loneliness is associated with a 26% increase in premature death, so death before we would expect it for a person. ...

Host Amber Smith: And a toxicologist offers some precautions about marijuana edibles.

Michael Hodgman, MD: ... In the home, what we encourage is to treat this like any other drug when you have young kids in the house. And that's doing things to keep them out of reach of children. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll explore loneliness and how it affects mental, physical and societal health. Then, a toxicologist shares precautions for marijuana edibles. But first, a look at elder orphans who have no children to care for them as they age.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Many adult children find themselves providing care to their aging parents, but what happens to people who do not have children as they age? Who takes care of these so-called "elder orphans"?

For some ideas about how this might work, I'm talking with Dr. Sharon Brangman. She's a Distinguished Service Professor of geriatrics and the chief of geriatrics at Upstate.

Welcome back to "HealthLink on Air," Dr. Brangman.

Sharon Brangman, MD: Hi. Thank you for having me again, Amber.

Host Amber Smith: Now, some people have spouses who become caregivers, and we'll be talking about that.

But there are also people who live happily on their own for decades, and then there's a health diagnosis or a fall down the stairs, and that suddenly upends their lives. So what happens when there are no adult children or no spouse to step in and help?

Sharon Brangman, MD: So that's a special challenge because we have found that caregivers provide a significant amount of care to people as they get older.

The government actually is happy to have somebody providing this care because it's not easily paid for by Medicare or even certain insurances unless you have long-term care insurance. So caregivers really help older people as they're aging, but increasingly we see people who either outlive all their relatives, or if they have relatives, they're not readily available.

But we also see people, especially women who never married or never had kids or maybe got divorced and have no kids. I also see people who have children who are either estranged or live far away, so they're not readily available to help when somebody starts to need care.

Host Amber Smith: And what happens if an older person with no family nearby arrives at the hospital, and they're incapacitated?

Would social workers try to find that person's primary care doctor?

Sharon Brangman, MD: Well, it's more than finding the primary care doctor, because when somebody comes to the hospital in the midst of a medical crisis, there are decisions to be made. And if that person is not able to make those decisions, and if they haven't appointed a guardian or a health care proxy to make those decisions for them, then that creates a problem for the health care team to figure out what is the best thing to do.

So that's one of the reasons why it is so important as we get older to make sure that we create a support network. And you don't want to wait until there's a crisis. Because when there's a crisis, then your options may be limited, or your wishes may not be carried out. So, in particular, if you are what they call an elder orphan or a solo elder, you need to make sure that you start thinking about things way before you need it.

And these are very hard conversations to have, because we have to start thinking about a time when we may not be independent, or we may have an illness that doesn't have an easy cure or an easy fix. And these are tough things to start talking about because we have to kind of confront our mortality and exactly what may be the end of life.

But if you avoid it, you are making a decision. By avoiding it, you are making a decision that you're not going to talk about it right now. And then when something comes up, as it inevitably does, the situation can easily get out of control.

Host Amber Smith: If planning ahead is key, what types of things does a person need to consider?

Sharon Brangman, MD: Well, it's very important for older adults who do not have immediate family to have a friend network. They need to create a group of friends, and hopefully some of them are younger than they are. They probably need to call an elder-care lawyer who can help guide them in organizing their finances, setting up a health care proxy.

Although you can set up a health care proxy without an attorney, a health care proxy is someone who steps in when you're not able to make decisions for yourself. And so that should be someone who knows you very well and knows what you would want because you want that health care proxy to not think about what they would want personally, but to really act on your behalf as to what you would want.

And that may involve a long conversation. Again, another tough conversation to have, but a conversation with that person so they really understand what your goals are and what you value.

Some people need to find a geriatric care manager, and a geriatric care manager is a professional who knows the resources in that region and can help arrange home care or a move even. They can help arrange someone to clear out their house if their house is cluttered. They can help you figure out what services you need.

And then you need someone you trust to be a backup for your finances. And that, again, could be an attorney or a trusted friend or even an official at the bank, for example.

So that you have somebody who can back you up financially, legally and in terms of your health decision-making, and then help you manage those decisions that have to be made to help you get through the day.

Host Amber Smith: What do you think about long-term care insurance? Is that a good deal?

Sharon Brangman, MD: So, long-term care insurance can be an important tool to help you finance your home care or your nursing home care. It is very expensive, so many people do not have the financial resources to afford it. And of course, the longer you wait to get it, the more expensive it is. So, that can be an important tool, and that would be something to talk with your financial adviser with to see how that would help.

Host Amber Smith: And I think a lot of people presume that Medicare will just take care of everything they need, but that's not the case, right?

Sharon Brangman, MD: That is the No. 1 conversation that we have with families because they think Medicare will pay for home care.

Medicare will pay for your hospital stay. It will pay for doctor visits. If you have Medicare Part D, it will pay for medications.

But for that day-to-day care that you need for someone to help you get dressed or take a bath or get to the grocery store, that is not covered by Medicare. Medicaid is a different program, and it's for people who are financially stressed and don't have any money, and Medicaid will provide some services, but usually not enough to meet most people's needs.

So Medicaid is an incomplete way of getting care in your home. It is, however, the biggest payer for nursing home care.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Sharon Brangman. She's a Distinguished Service Professor at Upstate and the chief of geriatrics.

If an older person who has a spouse becomes ill or injured, the spouse may be thrust into the role of caregiver, especially if there are no children who are able to help. Do you see that happen often?

Sharon Brangman, MD: So, yes, that is a very common phenomenon that comes up. Long-term spouses, for better or for worse, for sickness and in good health, are the ones to provide that support.

Now, even with the best of intentions, sometimes that spouse is not able to provide that support because of their own age or health problems. Or what we see is that we'll have two spouses or two partners who have health changes that happen on a different trajectory. So one may be further down the path of needing help than the other.

So this is another situation where you have to have that clear conversation. As tough as it can be, you have to have that conversation to start to make good decisions. For example, I've had some couples where they decide that they want to stay in their own home, and one of them may need home health assistance but the other one doesn't.

Or both of them may need home health assistance, but one may need more than the other. So, they, again, may need help identifying a person who could come in. This is where a geriatric care manager can be very helpful. And you can have two people in the same household getting some assistance, but each one has different needs.

Another option is to move into assisted living, where one person can get more care than the other. So we have a number of assisted living facilities in our area, which range from totally independent care, where you live in your own apartment, to more enriched care, where you have somebody come in to either give you medications or to help you get started in the morning or get ready for bed or whatever the needs are.

And again, one partner may need more care than the other, but they're in the same place.

Host Amber Smith: Sudden life changes, like we're talking about, can be difficult and challenging for all involved, and there's a lot of medical considerations as people age, but there's also emotional issues that come up, and I wanted to get your input on a couple of situations that listeners may be able to relate to.

The first one is a husband who was a working professional was married to a wife who kept the household. The husband had surgery and suffered a stroke, and since then, as the man has declined, the wife has been angry toward him to the point of verbal abuse, something a close friend has recognized.

What could this close friend do to help the situation?

Sharon Brangman, MD: So, this is actually not an uncommon situation. Even if somebody has the best of intentions, caregiving is very, very hard. And if you are working or have other responsibilities, it is extremely stressful. So to me, that is a caregiver who needs help.

There are, again, people who can come in and help assess the situation and see exactly what the care needs are.

You need an assessment of the financial resources to see what is affordable and then figure out a way to give that caregiver some respite or relief. You need to have a breather. Caregiving can be 24/7, 365 days a year, and many caregivers put the needs of their loved one ahead of themselves, so we have had caregivers who don't sleep well, don't eat well, may miss their own doctor's appointments because they're taking care of their loved one. And they are not healthy either, physically or emotionally. Everyone needs a break, and we need to help them figure out how to make that happen. It doesn't mean that you are weak or incapable, it just means that you're human, and you can't do it all by yourself.

Host Amber Smith: Another couple are retirees for more than 10 years, and both have been very active over the years. Now all of that activity has taken a toll on one of the partners, requiring repeated joint replacement surgeries, plus the development of an autoimmune disease that leaves this person fatigued. So, the partner who remains healthy is finding it hard to be gracious about declining abilities and thinks about all of the things they can no longer enjoy together and fears that the world is closing for them, too.

Is there anything that can help in this situation?

Sharon Brangman, MD: So, again, very common for two people to have a different health trajectory. So this is another opportunity for a discussion to talk about a way for one person to maybe maintain some of those previous activities that they enjoy doing and provide some respite for that person to get away and enjoy those activities and maybe the relationships associated with it, but make sure that the person who needs the care isn't being neglected and can get that support also.

It is hard. Most people can't do it on their own, and that resentment can often make people feel guilty. It makes feel like they're a bad person or they're selfish.

But it's a very normal reaction when you are faced with a huge, overwhelming problem to solve, and it just highlights that you need help to work it through. People feel like they're in it alone, and nobody has ever gone through something like this before, when in actuality it's very, very common and you don't have to reinvent the wheel, because most of us who do this kind of work every day have seen so many of these situations. And there is support, and there are resources out there. And we happen to live in an area, in Central New York, where there are resources that people can draw upon.

Host Amber Smith: Regarding mental and emotional problems of patients and of their caregivers. I'm talking about depression, anger, envy, others. These things might arise as the situation changes, but is it best to be proactive in some way or to wait and see if these things become a problem?

Sharon Brangman, MD: Well, it really depends on the person, because sometimes we worry about things that never happen. But it's also good to know what the possibilities are and what your options would be should they arise.

So this is where education is very important to kind of understand the disease trajectory, the care needs that might come up, so that you're aware of the options that are out there, and that you can sometimes get help predicting when you might need it. And that's one of the things that happens when you get a geriatric assessment in our office, is that sometimes we can help you see when those red flags may be waving.

So we do what's called anticipatory care, and we have things in place in anticipation of a need. Sometimes we can all be taken by surprise. Then you'd be able to gather those resources as quickly as you can.

Host Amber Smith: Dr. Brangman, I thank you so much for making time for this interview.

Sharon Brangman, MD: You're welcome. It's always a pleasure.

Host Amber Smith: My guest has been Dr. Sharon Brangman. She's a Distinguished Service Professor of geriatrics and the chief of geriatrics at Upstate.

I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," how loneliness affects mental, physical and societal health.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Earlier this year, the U.S. surgeon general, Dr. Vivek Murthy, released a report calling attention to the public health crisis of loneliness, isolation and lack of connection. It's something that can affect mental, physical and societal health in people of all ages.

For help understanding this report, I turned to child and adolescent psychiatrist Dr. Hilary Gamble. She's an assistant professor of psychiatry and behavioral sciences at Upstate.

Welcome to "HealthLink on Air," Dr. Gamble.

Hilary Gamble, MD: Thank you for having me.

Host Amber Smith: The surgeon general had to think this was important in order to issue an 82-page report called "Our Epidemic of Loneliness and Isolation." Do you think this is all because of the pandemic forcing us to socially distance?

Hilary Gamble, MD: Well, first of all, I'm so glad that we are broaching this topic. I think it's an important one to explore now and also retrospectively. According to the report, 50% of all Americans said that they felt lonely prior to the pandemic. So while I think that the pandemic certainly worsened that sense of isolation and loneliness in our population, I think there was a certain amount of that that predated our pandemic.

The lockdown loneliness, I think, has been a particular stressor, obviously, and not just in the United States, but worldwide. A recent study in the U.K. presented data that helped us to better understand, I think, the added impact of the lockdown loneliness. And the researchers showed us that there was certainly an increase in the amount of loneliness that people experienced during and relatively post-pandemic, I guess you could say at this point. And also there is a certainly an associated decline in mental health.

Host Amber Smith: Well, one of the things that preceded or was out there before the pandemic is social media. How much of that plays into the creation of loneliness and isolation?

Hilary Gamble, MD: So I think social media, definitely, is a tricky subject. I think that it can sometimes facilitate social connection and also definitely detract from our connections between one another.

If we look at the data specifically of our teens, age 13 to 17, 95% of those adolescents are engaged with using social media in one form or another. I think it's become so commonplace in the way we perform our jobs, interact with school, touch base with family and friends who are maybe far apart or across the world. So definitely there have been some advantages.

Americans have reported that they spend roughly six hours a day on digital media and a third of Americans report being on some sort of digital media almost constantly. You know, I think to say that that hasn't impacted us socially would be remiss. I think the extent of the impact is difficult to fully understand. Because again, there are both pros and cons to the use of social media, and so I think in order to fully understand it, we have to dive into how each individual interacts with social media or with digital media in general.

Host Amber Smith: We've heard about growing numbers of kids in adolescence with depression or suicide attempts. Do you think these cases begin with feelings of loneliness that go unrecognized or untreated?

Hilary Gamble, MD: I think in some instances, yes, as someone who sees children and adolescents who present to our emergency department at Upstate, or who follows or sees new consults for kids in our Golisano Children's Hospital, I can tell you subjectively, loneliness, a sense of isolation or even a more general sense of feeling alone or like people don't understand what they're going through, particularly in adolescents, I think can predispose to worsening mental health, for sure. In particular, we know via numerous studies that in teenagers, isolation is a red flag that we child psychiatrists certainly pay attention to when we hear during an interview.

And that is something that perks our ears and certainly forces us to, I think, more thoroughly explore other symptoms that could be present that could potentially warrant increased interventions in that population.

Host Amber Smith: Is it common for you to hear from your patients that they feel insignificant or, like, they are dealing with the stress of life all alone?

Hilary Gamble, MD: Yes, I think so, particularly for those who have identified of a struggle of some sort, whether it be worries, social worries or performance worries in school, or a sense of feeling down and disconnected. I think that lack of feeling understood by someone else can really exacerbate one's sense of loneliness.

Host Amber Smith: Well, let's talk about what social connections mean and why they matter. But first, what counts as a social connection? Are we talking about family members, or friends and acquaintances, or phone-call conversations? What is a social connection?

Hilary Gamble, MD: I think, boy, that is the question, isn't it? I think anything that enables us to interact with another person counts as a social connection or interaction, and I think because we all have our own individual needs for feeling social connected. It can look really differently from person to person. So I might have less of an innate need to feel connected to other people. I might be able to tolerate loneliness and be less adversely impacted by it than my sister, brother, parent. And they might have higher needs or wishes for social connection.

So I think that it's important, as we study loneliness and identify the impacts, and therefore theinterventions that could be helpful, that we make it individualized, based on one's particular needs and wishes.

Host Amber Smith: Do you think that some people are born to be more socially connected and outgoing, and others are just naturally more reclusive?

Hilary Gamble, MD: I mean, we know in child psychiatry that every person is born with a certain temperament. Now, the temperament certainly is not fixed in stone throughout one's life. We all know nature versus nurture here, and I think both elements play crucial roles in the development of a temperament and a personality.

And I think that depending on one's experience in life, whether someone is going through maybe the loss of a loved one or a family illness, or has a chronic medical illness, I think those can really raise the level, potentially, of the need for social connectedness versus someone who perceives things as going fairly well.

Now, that's not to say that people who perceive their lives as being very positive are immune to needing social connection. I don't mean that. I just mean that I think, again, as child psychiatrists, we think about development as a longitudinal entity that sort of ebbs and flows based on developmental level and the needs and the psychosocial stressors in one's life at the time.

Host Amber Smith: There seem to be people, though, who, when they're alone, they feel solitude versus anxiety because they're alone. What can we learn from those who feel the solitude that can help us be more like them?

Hilary Gamble, MD: So I think just like we all have our own temperaments, we all experience loneliness or solitude differently. For some people, I think solitude can be peaceful. Some people enjoy going for those quiet walks in the woods. Other people thrive by being surrounded by other people or animals, life of some sort.

And, again, that need might change. So sometimes we feel really overwhelmed or overstimulated. Maybe we've had a really busy week at work and a lot of demands placed on us. And maybe that would lead to us wanting a little bit of disconnection in order to reset ourselves so that we're ready to have additional connections in the future. So I think the work there is for each of us individually to take the pulse on our own needs and wants at the time, and allow ourselves the space to either seek out a social connection or not, to take some space for ourselves to reset.

Host Amber Smith:

Now, what are the risks to physical health in people who are lonely and isolated?

Hilary Gamble, MD: I'm so glad that we're speaking about this topic in particular, and I have to admit that when I read the surgeon general's report, I found some of the statistics staggering. So I do want to just review a few of those, for the folks who are listening today. I think they're very important, and I think they really drive home the impact, the gravity of the situation that we're facing now.

So the surgeon general reported that loneliness is associated with a 26% increase in premature death, so death before we would expect it for a person. Lacking social connection is equivalent to smoking 15 cigarettes per day. And childhood isolation results in increased rates of obesity, hypertension, or high blood pressure, and hyperglycemia, or high blood glucose, blood sugar levels, later in adulthood.

So of course, we've spoken thus far about the direct or more immediate impacts on our mental health, like depression and anxiety symptoms, for example. But this data suggests that not only do we struggle with the mental impacts of isolation and social disconnectedness, but also our bodies physically store that pain and inflammation and can manifest really quite troubling symptoms later in life.

Host Amber Smith: So, do we know yet, do those physical symptoms and diseases disappear if the loneliness dissipates?

Hilary Gamble, MD: I would like to think, yes. I think at this point we're lacking in data to support a strong conviction either way. I think what we know about depression and anxiety so far suggests that the sooner it's treated, the sooner our bodies can return to baseline and be free of that chronic inflammation and stress, the better the long-term health outcomes.

Host Amber Smith: So what do you do to help a child or adolescent who complains about feeling lonely? How do you help them?

Hilary Gamble, MD: I think helping adolescents requires a "village" approach, for sure. You think of adolescents as a time in which teens in general are individuating from their families. And by that I mean that adolescents at that stage start to form really strong peer relationships. And those relationships tend to strengthen as those with family become a little bit more strained. And this is a totally normal developmental stage and is really helpful later in life when you have to form adult-to-adult peer interactions and relationships.

I think sometimes it's difficult, I would imagine, for parents to stay attuned and present with adolescents during that process because naturally they're being pushed away. So my wish would be for parents to continue to stay present, and I realize that sounds vague. I think staying available and making it clear to the adolescent in words and in action that you will be a consistent presence, regardless of the adolescent's changes, can really provide a sense of security and validation for the child.

I think so often kids forget that their parents were also adolescents at one point, and we often hear, "You don't know what it's like. You've never been through this." And it's tempting to argue, right? And say, "I was a kid once, too."

But the simple fact is their experience IS different than the parents' experience. And so to validate that maybe it's not harder or easier, but certainly different, I think, can have a profound impact in allowing that child the opportunity to talk through the struggles and for the parent to be available when needed, I think, is most important during that time.

Host Amber Smith: Now, some social connections aren't necessarily positive. I'm thinking about gangs or extremist groups that may manipulate their members. Are you concerned about lonely kids being pulled into groups like that?

Hilary Gamble, MD: So I think that predators -- right? That's what we're talking about -- certainly prey on the feeling of isolation, the feeling that "nobody gets me." And when you're in that lonely spot, you are certainly susceptible to anyone or anything that provides validation or a sense of belonging. And like you're suggesting, a sense of belonging can be a really positive thing for some youth, or it can be horribly negative.

And I think that, unfortunately, with social media, we have so many outlets for people with malintentions to reach youth and to pose as people who are superficially supportive but really have an ulterior motive. So I think the isolation is scary.

I give parents a prescription to be extra annoying when I fear that a child or adolescent is isolating or pulling away from social connections, whether it be with friends or family. And I tell the parent, when your child gets angry at you for knocking on their door, checking in, you just blame me. I'll take it. So I invite them to check in more often and to be present because that certainly will decrease the likelihood of their child being a victim.

Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more of our talk about loneliness with Upstate child and adolescent psychiatrist Dr. Hilary Gamble.

Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith, and I'm talking about loneliness and isolation with child and adolescent psychiatrist Dr. Hilary Gamble.

Let me ask you a little more about advice you have for children and adolescents and their parents if they're struggling with feelings of loneliness. Are there bad habits that encourage loneliness?

Hilary Gamble, MD: I think sometimes the process is insidious, meaning we don't notice it until it's a problem. It seems to be kind of inching along, and then all of a sudden families get to a point where they notice they're disconnected from their child, or vice versa. And some of my work with children and families is to explore that process and wonder how we got to this point and what went awry. And there rarely is a simple answer.

Typically it's, "Well, you know, I wasn't feeling well," or "I had a couple of down days, and so I stayed in my room and I was on my video games more and more, and I snapped at my parents every time they came to check on me." And then the parent didn't want to annoy the child and make it worse. And fast-forward a few days or weeks, and now we're in a position where the child is really truly isolated and involved in who's knows what online, potentially, and parents feeling at a loss as to what to do.

So again, I just say, "Stay present." Raising children, as we know, is a marathon, not a sprint, right? And so a few days, a few difficult days of pushing into your teenager's life in a respectful way, I think, can mitigate some of these unfortunate consequences and inadvertent consequences of trying to do the right thing, but backing off when, really, people might need you to be more present as a parent or as a family.

Another thing that we often remind each other of in child psychiatry is this idea -- and it sounds very simple -- but we always say, let's try to meet the family or the child where they're at, meaning not everyone is ready to have family dinner every night. Not everyone is at that point where they can handle that. Sometimes it's a couple of check-ins during the day. Sometimes it's one activity a week. And I think that, again, the individualized approach is important to figure out where the struggle is and therefore where a reasonable intervention might be warranted. And I think we have to be mindful to set the bar at a place where the youth can achieve.

Host Amber Smith: Are medications ever part of it?

Hilary Gamble, MD: Sure. When kids meet criteria for bona fide anxiety or depression or other mental health disorders? Absolutely, medications are a part of our treatment. For the most part and for most disorders that we commonly see in children and adolescents, psychotherapy is a main first intervention, our first-line intervention, we call it.

Sometimes if symptoms are more moderate or severe, we do recommend a combination of psychotherapy and medications, but, of course, the psychotherapy doesn't have side effects, right? Like the medications do. So we like to at least start with that for a period of time to see if we can help the youth explore maybe where some of those blocks are, and come up with techniques to help to better cope with that pain that they're feeling inside.

Host Amber Smith: As a follow-up to what you were saying about family dinner, if the youth is so alienated that they can't bear to be together with their family, do they just eat in their room, or what does the family do for that?

Hilary Gamble, MD: I do have some teens that spend a lot of time in their room. I also see a lot of teens who have, like we said, these very strong friend connections. And sometimes they're spending increasing amount of time at friends' houses with other families, and that's not always a bad thing. So sometimes these other families can have really positive impacts. Sometimes these kids can serve as pseudo older brothers or sisters for their friend's younger siblings.

So there are all these dynamics that we better understand once we hear the story. Because on the surface you might hear, "my son's never home for dinner," or whatever, but we find out that that child has actually made a really strong connection with a great friend in school who has a wonderful family and there are little siblings, and he or she has served as like a wonderful older sibling figure for this family.

So, again, creating the narrative and giving space for that and better understanding the reason for the disconnection and what might be driving it. And, if it truly is disconnection, or maybe just a different relationship, that can be very telling.

Host Amber Smith: Is it helpful to tell someone who complains of being lonely to get out there and volunteer or go join this or that? I mean, just the act of being around people. Is that going to help with the loneliness?

Hilary Gamble, MD: Sure. We have this old adage, right? Just smile and you'll feel better; it naturally takes less energy to smile than it does to frown; and all these kinds of sayings. When people are truly suffering with depression -- now, I'm getting a little bit clinical here -- but when people are truly depressed, they generally lack motivation and the ability to feel that joy. So while it may make you, as the suggester of the activity, feel better, like the person is getting out and doing something, that might not have intrinsic value to the person.

And once people start to recover, we notice actually that the people around them see the improvement first, before the person feels better themselves, which speaks a little bit to what you're talking about here, I think. So, can the activity help? Yes. Physical activity, we know, can certainly lower stress hormones. However, the lack of motivation can stand in the way. And I think we just have to be mindful of the tendency for people who are already suffering to feel guilty about it.

And, like I said, when we set the bar, or we make expectations, the important factor is to make sure that we're setting expectations that the person can achieve so that they build confidence and want to do even more next time. If we set the bar too high, and they don't achieve it, then that actually could really exacerbate the symptoms, right, of feeling like a failure, feeling alone or not heard.

Host Amber Smith: Are there changes to society and the way we live today that you think could help overall with this crisis of loneliness?

Hilary Gamble, MD: Gosh, that's the million dollar question, isn't it? I wish I had a thorough or concrete answer to that. As we spoke in the very beginning of this talk, technology certainly has advantages and disadvantages. I think the balance here is of the utmost importance. So our technology has the opportunity to both augment and detract from our social connection.

We all use it differently, and if nothing else, I hope that maybe after listening to this talk, people are able to have at least an honest dialogue about how they're using digital media, how they're using social media, and are they using it to augment social connectedness or is it potentially detracting from the connectedness that they could feel with others?

Host Amber Smith: Well, Dr. Gamble, thank you so much for making time for this interview.

Hilary Gamble, MD: I appreciate you having me. Thank you very much.

Host Amber Smith: My guest has been Dr. HIlary Gamble. She's an assistant professor of psychiatry and behavioral sciences at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from Dr. Michael Hodgman, a toxicologist in Upstate's department of emergency medicine and the Upstate New York Poison Center. What's important to know about marijuana edibles?

Michael Hodgman, MD: Edible products are the growth industry or growth product for marijuana producers, you might say. For example, in Canada, they legalized marijuana. I don't recall the (year), maybe 2019 or so. But it was about a year later before retail sales were allowed in Ontario, and on the first day there were retail recreational marijuana products for sale, the stores in Ontario sold out of edible products. I mean, it was, it was crazy.

And we're seeing the same thing in other states, where the products that are having the greatest year-to-year change in growth are these edible products. These edibles are very attractive. They look like candy. They look like food. There's infused beverages. We've even had a few cases with infused hot sauce, infused barbecue chips. I mean, it's just crazy.

I think the No. 1 exposure product that we get called to the poison center are gummies. I mean, they're just unbelievably popular. And again, they're easy to leave laying around, and these young kids get into them, and it's been a real issue.

Our real focus is on prevention, and particularly in young kids with edibles. And so, in the home, what we encourage is to treat this like any other drug when you have young kids in the house. And that's doing things to keep them out of reach of children. And one thing we in particular support here is the use of a lockbox, like you might for your medications. Use a lockbox to keep your edibles in it as well, and try and reduce that potential that one of your kids is going to accidentally get into one of these products.

Here in New York state, now that marijuana is legal, there are very specific packaging laws for these products so that the packaging has to be child resistant and tamper-proof. And it has to not be attractive to children. I mean, it's not supposed to look like a candy. You know unfortunately, there's a lot of illicit products out there that violate every one of those rules. So a lot of these products, they're not following the New York state labeling.

But if the label's proper, first of all, it's got to be kind of a bland label with bland font for the print. It can't be like real colorful print or anything. And it has to have what the total amount of THC is in the package, what the unit dose is, there's also rules on the maximum unit dose that's allowable as a recreational marijuana product.

The maximum unit dose for a single dose for an adult is 10 milligrams. And so the product has to have that, the total dose. It also has to have precautions on it about the differences in when you experience the clinical effects when you ingest THC (tetrahydrocannabinol) versus when you smoke it.

When you smoke marijuana, the absorption through the lungs is very rapid to the brain, and the clinical effects are within minutes. When someone ingests a THC edible, the onset of clinical effects may not be for 60 to 90 minutes after you ingest the product. And there's a real risk there. Somebody can take it and a half hour later say, "Huh, nothing's happened. I'm going to eat another one." This is something we call 'dose stacking.' And so by the time you start getting the effect from the first one, then there's more after that. So the onset of effects is delayed, and that can affect anyone who's not aware of that. And the duration of effects from edibles is more prolonged than it is from smoking because, again, when somebody smokes it, they have the clinical effect very rapidly. And so they're able to titrate (adjust) the effect because then they stop. Whereas with these edibles, if you've still got more that's going into your system, it can last a lot longer.

The other problem with young kids is whatever a unit dose is, that's a big dose for a little child. When you consider that a 10-milligram dose is what an adult should get. You get a 2-year-old that takes that same dose, that's a lot more. But the problem is also it's a gummy. It tastes good. Or it's a piece of candy. It tastes good. So how many stop with one or two pieces of candy, or how many people have only eaten one barbecue chip? The dose effect in these young kids can be really, really significant.

We don't know, sometimes, how many they took. But if we just consider maybe a 2-year-old child that weighs let's say, 30 pounds, or about 15 kilograms that would be. And there have been some estimates that a dangerous dose in a kid that age could be , about 1.7 milligrams per kilogram, or that might be maybe 25 milligrams. So you could say a kid, a young child who just eats two to three gummies, they've already crossed that threshold to the potential for severe intoxication.

A lot of the kids that we see that just get into a few, I mean their clinical course is like you might expect with an adult. They're a little goofy, a little lethargic. Their behavior isn't quite normal. But then the more severe effects, we can sometimes see, is really profound sedation. Paradoxically, some kids will get very, very agitated and restless. And so we can see the whole spectrum of changes there.

Host Amber Smith: You've been listening to toxicologist Michael Hodgman from Upstate's department of emergency medicine and the Upstate New York Poison Center.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Aging can assume many guises. Poet Lisa Wiley teaches English at Erie Community College in Buffalo, New York. Her poem "Sundowning" describes a common occurrence in elder care, the eternal hope that this time the parent might remain calm and be able to sleep.

"Sundowning"

I used to race the feathered sunset

on summer nights when I embarked too late,

realized I had too many miles to make it home

before stars pierced an indigo sky.

I'd sport a white t-shirt so traffic might see me

a scout leader neighbor would pull over

to my side of the road, instructing me

to wear a headlight or start earlier.

I'd just pump my arms harder.

Now we race to my father-in-law's side

on late winter afternoons

when a cotton candy sun drops too soon

on his sharp, mathematical mind.

Gentle, humble, Teddy bear, his students said.

If we arrive in time, we guide him through

simple tasks like shaving, as he offers

lucid moments of secret childhood handshakes

before bedtime combat settles in.

Joanne Clarkson has published five poetry collections. Her poem "The Last Piece" describes a part of her job that was probably never in the job description, but which defines caring for the vulnerable.

"The Last Piece"

When, as a nurse, I visited homes

of the dying, jigsaw puzzles

were often spread across tables: kitchen,

coffee, card, bedside.

A thousand pieces a common theme.

I watched a wolf come together

in the woodlands. An orca leap

from the Salish Sea.

"It passes the time," Karl, always cheerful,

explained as his ragged heart stuttered

then thrummed. "It all makes sense this way,"

John's wife Nancy told me

since John could no longer speak.

It gave visitors something to explore

besides grief. They felt useful

finding a splinter of the weathered barn.

I drove boxes of fragments from house to house,

trading, and never lost a piece

as I listened to the whining breath

and measured pain on an impossible scale.

Karl gave away every puzzle except

the wolf. His daughter glued it

to a board, framed it after, tribute

to small connections

when the greatest was taken away.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," the impact exercise can have on cancer risk and on cancer treatment.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

This is your host, Amber Smith, thanking you for listening.