The New Old Age Blog: In the Middle: Helping Unhappy Couples

A post on Monday discussed the forces that can make an older couple’s good marriage suddenly go bad — an array of subtle, and often-misunderstood, mental, physical and emotional factors that can upset the equilibrium of even the happiest marriages.

Now we have consulted marriage counselors and geriatricians to find out what caregivers — either the grown children of the couple, or one of the spouses involved– can do to help restore peace and balance to these relationships. The experts consulted uniformly agreed that even older people can at least take steps to reduce tensions and improve their relationship, even if they cannot actually change. (Really, who can, at any age?)

“Even though the situation may seem overwhelming, take heart,” said Dr. Gordon Herz, a psychologist in private practice in Madison, Wisc., who specializes in neuropsychology and rehabilitation psychology. “Couples who have been together for 60 years tend to have worked out ways to manage conflict – or they wouldn’t still be together.”

Retreat to a neutral corner

When grown children see their parents fight, many want to run and hide. But those who are assuming an increased caregiving role often feel impelled to jump in and “fix” the problem, as they do with the other caregiving issues.

If you are so inclined, experts speak with one loud voice to advise: Don’t!

Trying to act as emotional broker between your parents can backfire. (Now they tell me! Suffice it to say that after one such effort my sister said to me in not exactly the friendliest tone, “Well, that went well, didn’t it?”)

“It’s better if your parents can find somebody else to talk to than you,” said Dr. Nancy K. Schlossberg, professor emerita of counseling psychology at the University of Maryland and the author of “Overwhelmed: Coping With Life’s Ups and Downs.”

Don’t give up on marital therapy

“Marital therapy for individuals over 65 years of age is difficult, since habits of a lifetime are deeply ingrained,” stated a study in The Canadian Journal of Medicine, one of the few in the medical literature about marital therapy among older people.

“Yet, in a sense, marital therapy is more crucial for the elderly than for younger patients,” the study continued. “At a time when they are least adaptable and most vulnerable to stress and are entering perhaps the most difficult period of their lives, the elderly must learn new methods of relating and coping” because of the physical and mental changes described in our earlier post.

There’s another reason learning to cope with life changes as a couple is even more critical for older couples: Unlike younger couples, the elderly are rarely in a position to leave the marriage and start over.

Help at least one spouse get counseling

What if only half the couple is ready to seek counseling? Not a problem, therapists said. “You want to help the part of the couple that is suffering,” said Dr. Elaine Rodino, a therapist in private practice in State College, Penn. “The other person may still be the curmudgeon, but I think of it as the law of physics: When you change one aspect of the formula, things change in the total.”

When dementia affects one of the spouses, therapy can help the caregiving spouse learn coping techniques, “which can reduce the marital discord and stress that can make conditions, especially cognitive difficulties, worse,” said Dr. William Dale, chief of geriatrics at the University of Chicago Geriatrics Medicine.

Consider the general practitioner or internist

If the couple won’t see a marriage counselor or therapist, can a family doctor be of any use? The experts had mixed responses.

Many pointed out that general practitioners have neither the time nor the training to offer much relationship help, unless the origin of the problem is exclusively physical. Others thought they could be of use, if given a little direction from the family.

“I encourage the kids to talk to the doctor in advance and let him know something is going on – signs of depression or other problems the parents won’t talk about,” advised Dr. Dale, adding that a consultation with a geriatrician who is more familiar with problems of the aging might be even more productive. “Then the doctor can say, ‘Gee, you sound really frustrated or down — are there any reasons we can explore?’”

Don’t overlook the importance of intimacy

“Mutually stimulating sexual relationships need care and feeding by both partners at any age, but especially in the geriatric years,” according to a study on marital therapy for the elderly. “The need for physical contact, warmth and touching perhaps reaches a peak in this age of loneliness, decreased self-esteem and poor health.”

Forget the idea that elderly couples are too shy to talk about intimacy, insisted Dr. Rodino. “I saw a couple in their 80s, the husband was getting penile injections at the doctor’s office, and then they hurried home to have sex.”

But Dr. Rodino does concede that for older patients it is especially important to focus not only on sexual function and performance, but on “touching, and non-intercourse sexual relations; I help them rekindle the affection and emotional closeness,” Dr. Rodino said.

Address any neuropsychological issues.

To find out whether the sudden marital conflict may stem from early mental cognitive impairment (M.C.I.) —or to rule M.C.I. out and find the real source of trouble — make sure the spouse obtains a full neuropsychological evaluation. If it is M.C.I., “it convinces everybody that there is more than just abstinence, it’s not a personality problem — and they need to address it,” said Dr. Dale.

Don’t overlook simple solutions

“Sometimes a memory problem is something simple, like low Vitamin B12, that is easily fixed,” said Dr. Dale. “Or hypothyroidism, which is quite common, can affect memory.”

In that case, doctors administer synthroid, a thyroid hormone replacement that Dr. Dale said is “very safe, with almost no side effects.” Other changes in behavior can also be the result of a simple problem or be remedied by a change in medication. Don’t assume the worst.

Put an end to the blame game

Help reframe the problem. “Even if dementia is involved, let them know it’s not that their partner hates them, it’s that he is having cognitive changes,” said Dr. Linda Waite, director of the Center on Demography and Economics of Aging at NORC/University of Chicago.

“When you re-frame it like that, it’s easier for the spouse not to take it personally and not blame themselves and feel it’s something they did,” said Dr. Waite. “It can make a difference.”

A 2009 study in the journal Gerontologist supports this notion: “Care partners likely would benefit from strategies aimed at reducing self-blame, enhancing coping skills … and communicating effectively with the person with M.C.I and significant others.”

Separate the anxiety

Divide and conquer — time away improves time together.

“Older couples, especially those with disabilities, spend way too much time together,” said Dr. Lisa Gwyther, director of the Duke Center for Aging Family Support Program. “It would be a problem for any couple.”

Caregivers can best help by arranging for an activity or outing that each spouse can do separately so they can return to each other refreshed and more cheerful. “That can help a lot,” said Dr. Gwyther.

Dial down the tone

For spouse caregivers, it is important to watch not just what is said, but how it is said. In any relationship, tone influences our interpretation of what our partner says. Those with M.C.I. will especially react to tone, rather than the substance of the exchange, Dr. Dale said.

“Ratchet down the emotions, repeat things calmly,” Dr. Dale said. The person with cognitive problems doesn’t know he asked the same question five times — he only knows that you sound angry at him for no reason he can fathom. One spouse’s anger fuels the other’s, and pretty soon there is a fight or withdrawal.

Zero tolerance for violence

If a spouse becomes violent, “that’s an entirely different issue,” said Dr. Schlossberg. “Call in an expert on family violence” or the police.

Help them help others

Nobody likes feeling dependent and having to ask for help. Finding a way to have your loved one volunteer, help others and continue to feel useful can improve moods and marital interactions – even if M.C.I. is involved.

With one couple Dr. Gwyther saw, the wife was not only “driving her husband nuts because she was asking him the same questions over and over,” but she could no longer drive and deliver food in a mobile meals program as she used to. “So her husband agreed to be the driver — and she took the meals to the doors,” Dr. Gwyther recalled.”It made her feel good to continue to do that — and it made them feel good to do it together.”

Caregiver, heal thyself

You have heard it a million times here and elsewhere but, unlike us, this advice never gets old.

If you are exhausted from caregiving, you are bound to be cranky, and that will make everybody around you edgy and irritable, too — especially the spouse who requires your care. Taking the time to look after your own health and engage in activities that bring you pleasure can go a long way toward reducing stress and reestablishing a peaceful balance in a marriage.

How have you coped with tensions in your marriage — or in your elderly parents’ marriage, as you care for them in their old age? Share in the comments below.

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Bits Blog: What Instagram's New Terms of Service Mean for You

Instagram released an updated version of its privacy policy and terms of service on Monday, and they include lengthy stipulations on how photographs uploaded by users may be used by Instagram and its parent company, Facebook.

The changes, which will go into effect Jan. 16, will not apply to pictures shared before that date.

Facebook and Instagram have both hinted at plans to incorporate advertisements into Instagram’s application, although they have declined to provide details about how and when ads would be deployed. These freshly drafted terms give the first glimpse of what the companies might have planned. Here’s a quick rundown of what the new terms, the most significant changes in Instagram’s short history, could mean for users.

1. Instagram can share information about its users with Facebook, its parent company, as well as outside affiliates and advertisers.
Instagram said that the changes to its privacy policy are a means to help Instagram “function more easily as part of Facebook by being able to share info between the two groups.” The potentially lucrative move will let advertisers in Facebook’s ad network use data and information that users have shared on Instagram, like details about favorite places, bands, restaurants or hobbies, to better target ads at those users.

2. You could star in an advertisement — without your knowledge.
A section of the new terms of service, titled “Rights,” notes that Instagram will also be able to use your photographs and identity in advertisements. “You agree that a business or other entity may pay us to display your username, likeness, photos (along with any associated metadata), and/or actions you take, in connection with paid or sponsored content or promotions, without any compensation to you,” the new terms say. This means that photographs uploaded to Instagram could end up in an advertisement on the service or on Facebook. In addition, someone who doesn’t use Instagram could end up in an advertisement if they have their photograph snapped and shared on the service by a friend. Facebook already runs ads that make use of people’s activity on its site.

Marc Rotenberg, executive director of the Electronic Privacy Information Center, an advocacy group in Washington, said that the use of a person’s likeness in ads could run into some state laws protecting people’s privacy.

“Most states have laws that limit the use of a person’s ‘name or likeness’ for commercial purposes without consent,” Mr. Rotenberg said. “The legal purpose is to allow people to obtain the commercial value of their images and endorsements, which is a big issue for celebrities and others, but also a reasonable concern for Facebook users whose images are used by Facebook to encourage friends to buy products and services.”

3. Underage users are not exempt.
Athough Instagram says people must be at least 13 years old to sign up for the service, the new terms note that if a teenager signs up, they are agreeing that a parent or guardian is aware that their image, username and photos can also be used in ads.

4. Ads may not be labeled as ads.
In another section of the updated terms, the company says ads will not necessarily be labeled as ads. “You acknowledge that we may not always identify paid services, sponsored content, or commercial communications as such,” the company wrote.

5. Want to opt out? Delete your account.
The only way to opt out of the new Instagram terms is to not use the service. If you log into Instagram in any way, including through the Web site, mobile applications or any other services offered by Instagram, you agree to have your content used in ads. Instagram’s new terms of service say that “by accessing or using the Instagram website, the Instagram service, or any applications (including mobile applications) made available by Instagram (together, the “Service”), however accessed, you agree to be bound by these terms of use.”

Instagram addressed the changes on its company blog, saying that “nothing has changed about your photos’ ownership or who can see them.” In its blog post, Instagram said the changes would primarily help the company combat spam, which has plagued the application as it has swelled in popularity.

“Our updated terms of service help protect you, and prevent spam and abuse as we grow,” the company wrote.

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IHT Rendezvous: In Philippines, a Turning Point on Contraception

HONG KONG — There was both recrimination and celebration after the passage of a landmark bill in the Philippines on Monday, a measure that codifies sex education in schools and broadens access to condoms and birth control pills in poor and rural areas.

Versions of the bill had languished for more than a decade, as my colleague Floyd Whaley reported in The New York Times, because of staunch opposition from the Roman Catholic Church. About 80 percent of Filipinos are Catholic.

The reproductive health measure, locally known as the RH bill, passed in the House of Representatives by a vote of 133 to 79, with 7 abstentions. (The bill had earlier passed the Senate, 13 to 8.)

Opponents of the bill were furious that 62 members of the House had not shown up for the vote.

“There is still a burning question that needs to be answered: Where were the other congressmen in time of such a crucial vote like the RH bill?” said the Pro-Life Philippines Foundation, which called the bill “ungodly” and published a list of the “Judases” who did not vote.

“This is evil itself at work,” the foundation said on its Web site.

Catholic bishops have said they would work to defeat any supporters of the law in elections next year.

But Edcel Lagman, the congressman who sponsored the bill, played down those warnings, saying, “It’s more of a threat than a reality. The experience in other Catholic countries is once a law is passed on reproductive health, even the church supports the law.”

One of the congressmen who missed the vote was Manny Pacquiao, the acclaimed welterweight boxer and almost certainly the most famous person in the Philippines. He was elected to the House in 2010 to represent Sarangani, located on the southern tip of the island of Mindanao.

Mr. Pacquiao was knocked cold in a non-title fight in Las Vegas on Dec. 8, losing to Juan Manuel Márquez of Mexico. Three days later, on the floor of the House in suburban Manila, he spoke against the reproductive health bill, which was up for a preliminary vote. After receiving a rousing standing ovation from his fellow lawmakers, he said, “Manny Pacquiao is pro-life. Manny Pacquiao votes ‘no’ to House Bill No. 4244.”

A condensed excerpt of Mr. Pacquiao’s remarks:

In the dying seconds of the sixth round of my fight against Marquez, a single punch knocked me out. For more than two minutes, I was lying unconscious, motionless. My wife cried . . . my friends and fans cried when they saw me not moving at all. Some thought I was dead. They thought another life had been lost.

What happened in Vegas strengthened my already firm belief in the sanctity of life, on whether a person’s right to live in this world should be put in the hands of his fellow man.

One of the most outspoken opponents of the bill was Senator Vicente C. Sotto III, widely known as Tito. He wanted to block teenagers from obtaining contraception, arguing that it would encourage young people to have sex.

Another congressman, Romero Quimbo, called Miro, was in the hospital on Monday, suffering from dengue fever, although he got permission to leave briefly so he could vote for the bill. Afterward, he tweeted a photo of himself in an ambulance heading back to the hospital.

Amnesty International generally applauded the passage of the bill, although the group noted that the current version was “imperfect” because it required girls under 18 to have written parental consent before getting contraceptives.

“The Philippines still have a long way to fully respect, protect and fulfill women’s right to reproductive health,” said Polly Truscott, Amnesty’s deputy Asia-Pacific director.

The new bill does not affect abortions, which remain illegal in the Philippines.

The final version of the law can still be tweaked by legislators before it is sent to President Benigno S. Aquino III for his signature.

Mr. Aquino was vocal in his support for the measure, and his spokesman, Edwin Lacierda, said Monday, “The people now have the government on their side as they raise their families in a manner that is just and empowered.”

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DealBook: Sprint Reaches Deal to Buy Out Clearwire

Sprint announced on Monday that it had reached an agreement to buy the nearly 50 percent stake in Clearwire that it did not already own for $2.97 a share — a bump up from the $2.90 a share that was offered on Thursday.

The improved $2.2 billion offer, Sprint said, represents a premium of 128 percent over Clearwire’s stock price in early October before speculation emerged — following SoftBank‘s investment in Sprint — that Sprint would seek to buy out the wireless network operator.

Sprint already owns 51.7 percent of Clearwire. Buying the rest would give it full control over spectrum that it could use to build out its network.

Sprint is able to complete the deal thanks to cash from SoftBank of Japan, which agreed in October to a $20.1 billion transaction to gain majority control of the American telecommunications company, which lags far behind the market leaders, AT&T and Verizon Wireless.

The deal would allow Sprint to expand its Long-Term Evolution network, which is based upon the same data standard used by the newest generation of smartphones. Clearwire owns spectrum that is similar to what SoftBank uses in Japan, potentially giving the newly strengthened Sprint more clout in ordering the latest devices.

The chief executive of Sprint, Dan Hesse, said in a statement: “Today’s transaction marks yet another significant step in Sprint’s improved competitive position and ability to offer customers better products, more choices and better services. Sprint is uniquely positioned to maximize the value of Clearwire’s spectrum and efficiently deploy it to increase Sprint’s network capacity.”

Clearwire’s board approved the offer based on the recommendation of a special committee of directors not appointed by Sprint. Clearwire also has commitments from Comcast, Intel and Bright House Networks, which collectively own 13 percent of the voting shares, to support the deal.

Some of Clearwire’s minority shareholders believed that the company should hold out for a higher price, with one analyst calling for at least $5 a share. One of these investors, Crest Financial, said that it would try to block Sprint’s deal with Softbank if the earlier offer of $2.90 a share went through.

And another, Mount Kellett, had argued that based on what AT&T paid for roughly similar spectrum, Sprint should be paying at least four times as much.

But Sprint argued privately that its previous bid valued the network operator’s spectrum at about the same level that Verizon paid for spectrum that it acquired from cable companies, according to a person briefed on the matter. And Clearwire’s spectrum, Sprint claimed, is of lower quality and therefore less valuable, meaning that the company was effectively paying more than Verizon did.

Clearwire has struggled to to join the ranks of the biggest American cellphone service providers, despite bringing on big-name investors. Some of its previous stakeholders, including Google and Time Warner Cable, chose to sell off their holdings for a fraction of their purchase prices.

Agreeing to the deal announced Monday will help shore up Clearwire’s finances, at a time when it projected having enough cash to last a year or so and still faces significant debt obligations. Sprint has pledged to provide up to $800 million in interim financing to the network operator.

Citigroup and the law firms of Skadden, Arps, Slate, Meagher & Flom and King & Spalding advised Sprint. The Raine Group acted as financial adviser to SoftBank and Morrison Foerster acted as counsel to SoftBank.

Evercore Partners and the law firm Kirkland & Ellisa advised Clearwire. Centerview Partners acted as financial adviser and Simpson Thacher & Bartlett and Richards, Layton & Finger acted as counsel to Clearwire’s special committee. Blackstone Advisory Partners advised Clearwire on restructuring matters. Credit Suisse acted as financial adviser and Gibson Dunn & Crutcher acted as counsel to Intel.

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The New Old Age Blog: In the Middle: Why Elderly Couples Fight

George and Gracie (let’s call them that because using their real names would make them even unhappier than they already appear to be) are in their 80s and married for more than 65 years. Until recently they seemed to ride the waves that are inevitable in any marriage that spans nearly seven decades; through good and bad, they were partners and best friends.

But lately — ever since her hospitalization and his fall — they have been arguing more bitterly than usual (“Do you have to make such a mess in the kitchen?”), criticizing each other (“Why haven’t you dealt with the insurance company yet?”), withdrawing from each other, and generally making each other more miserable, more often than ever before.

This kind of degenerative relationship is not uncommon among the elderly in even the happiest marriages, marriage therapists and geriatricians said. But that is small comfort to either the couple in the middle of the maelstrom, or the children who care for them, as evidenced by a number postings on caregiver blogs. As some of the children have wondered there: “Why can’t we all just get along?”

Therapists and others who work with the elderly said the first step to addressing the problem is understanding where it came from.

“A key question is whether the marital bickering is part of a lifelong marital style or a change,” said Dr. Linda Waite, director of the Center on Aging at NORC/University of Chicago. Is it new behavior – or just new to the grown children who are suddenly so deeply enmeshed in their parents’ lives that they are only now noticing that something is amiss?

How much of the problem is really just the marriage style? “Some couples like to fight and argue – it keeps their adrenaline going,” said Dr. Nancy K. Schlossberg, professor emerita of counseling psychology at the University of Maryland and author of “Overwhelmed: Coping with Life’s Ups and Downs.”

Sometimes the best judges of whether there is a problem are outsiders, said Dr. William Dale, chief of geriatrics at the University of Chicago Geriatrics Medicine. Pay attention if someone says, “‘Gee, Mom seems more argumentative or withdrawn than the last time I saw her,’” Dr. Dale advised.

If the tone or severity of the marital tensions seem new, then it is important to find out why. The causes could be mental or physical, doctors say.

On the mental front, increased anger and fighting could be one of the first signs of mild cognitive impairment, a precursor of dementia or Alzheimer’s, in one or both of the spouses, said Dr. Lisa Gwyther, director of the Duke Center for Aging Family Support Program and Associate Professor in the Department of Psychiatry and Behavioral Sciences.

Dr. Dale concurs: “There is good evidence that the earliest signs of cognitive impairment are often emotional changes” — anger, anxiety, depression — “rather than cognitive ones” — memory, abstract thought.

But these early signs of cognitive decline can be so subtle that neither the spouses themselves, or their grown children, recognize them for what they are, Dr. Gwyther said. So husband and wife blame each other for the changes and allow feelings of hurt and resentment to grow.

Withdrawing from activities that used to give them pleasure can be a telltale sign of mild cognitive impairment – and can trigger anger and arguments.

“In one couple, the husband just didn’t want to participate in the holidays — the wife got angry and said he was being lazy and stubborn,” said Dr. Gwyther. But the truth was that his cognitive decline made all the activity overwhelming, and he didn’t want anyone to know that he was anxious about not remembering everyone’s names and embarrassing himself.

Suspicion and paranoia can also accompany mild cognitive decline and precipitate distrust and hurtful accusations. Dr. Gwyther recalled another woman who “called her daughter frantic because she said her husband dropped her at her chemo appointment, went to park the car, and didn’t return to get her.” The woman couldn’t imagine that her husband could possibly have lost his sense of time and direction, Dr. Gwyther added. She took it personally, complaining to her daughter that “your father doesn’t seem to care any more.”

Dr. Dale told of a spouse who accused her mate of infidelity because “she was convinced that when he was out grocery shopping he was really having an affair.”

Hoarding, an early symptom of mild cognitive impairment, can also create tension in a marriage. (For new treatments, see this recent post by my colleague Paula Span.)

When one couple came to a counseling session with Dr. Norman Abeles, emeritus professor of psychology and former director of psychological clinic at Michigan State University, the hoarding spouse finally said, “she did it because she thought that they would run out of money, even though there was enough money to go around.” Dr. Abeles said that incident led to her diagnosis of mild cognitive impairment.

Adding to the confusion, mild cognitive impairment (M.C.I.) comes and goes. “There are good days and bad days, good hours and bad hours,” said Dr. Gwyther. “Alzheimer’s and dementia don’t start on Tuesday — it’s a slow insidious onset.” But the diagnosis is becoming more common: The Institute for Dementia Research and Prevention predicts that 1 in 6 women, and 1 in 10 men, who live past the age of 55 will develop dementia in their lifetime.

“Spouses find it difficult to know when their partner with M.C.I. is acting differently (usually badly) due to the advancing illness or due to ‘willful’ personality issues,” said Dr. Dale, citing a 2007 study in the journal Family Relations exploring the problems this can create for couples.

Blaming is often easier than understanding. Another of Dr. Gwyther’s patients was furious at her husband for not filing their taxes. “He’s a C.P.A.,” she said. “How could we owe back taxes?” It did not occur to her that he might be unable to handle that task — and was too frightened about his deteriorating mental focus to let her know.

But as harmful as mental decline can be for a marriage, it is just part of the equation. Physical ailments – even those that seem completely unrelated to marital relations – “can upset the equilibrium of the marriage,” according to a study in the Canadian Medical Association Journal.

“Most men get angry at what’s happened to them when they get ill, women get angry and scared when he’s not what he used to be — so they fight,” said Dr. Schlossberg.

Chronic illnesses, like diabetes, arthritis and heart disease, can have a strong negative effect on mood, said Dr. Waite, who will soon be publishing a study on the subject. Diabetes is so often accompanied by depression that, Dr. Waite said, “one of my colleagues argues that that it is even part of the disease.”

And ailments can have an effect on a couple’s sex life — which can compound the marital problems, doctors said.

“Diabetes brings on neuropathy,” said Dr. Waite. “That means touching and feeling in sex is not as rewarding.” Without the pleasures of affectionate touching — whether a passing hug at the sink, or more — tensions can build. That’s why, if a couple is having problems with sex, they are more likely to have problems in the relationship — and vice versa, according to a 2007 New England Journal of Medicine study of sex and health among older adults.

Other changes in circumstances — retirement, shifting roles, the loss of autonomy, disparities in health and abilities — can wreak havoc. Losing independence can feel like losing oneself — and if you don’t know who you are any more, how can you know how to relate to your spouse?

“Fighting may come from a misguided notion that you can regain power by asserting it over your spouse,” said Dr. Schlossberg, whose observations are echoed in a 1984 study in the Canadian Journal of Medicine. “It doesn’t work, it’s false power – but they’ll try anything.”

The sheer exhaustion that can come from being the caregiving spouse is also bound to “make them stressed and angry,” said Dr. Waite. Not to mention guilty and resentful — never a prescription for happy marital relations.

“Part of the trap for the caregiver is the idea that you have to do it all, and the guilt you feel when you cannot live up to it,” said Dr. Gordon Herz, a psychologist in private practice in Madison, Wisc. Not surprisingly, resentment can soon follow, Dr. Herz added, because it’s hard to admit to anyone that, “‘this is too much for me.’”

What can outside caregivers — children or other loved ones — do about these golden marriages on the rocks? Should they intervene — or butt out? And can marital therapy help — or is it too late to change?

Share your thoughts and experiences — and tomorrow we’ll try to provide some advice from experts.

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The New Old Age Blog: In the Middle: Why Elderly Couples Fight

George and Gracie (let’s call them that because using their real names would make them even unhappier than they already appear to be) are in their 80s and married for more than 65 years. Until recently they seemed to ride the waves that are inevitable in any marriage that spans nearly seven decades; through good and bad, they were partners and best friends.

But lately — ever since her hospitalization and his fall — they have been arguing more bitterly than usual (“Do you have to make such a mess in the kitchen?”), criticizing each other (“Why haven’t you dealt with the insurance company yet?”), withdrawing from each other, and generally making each other more miserable, more often than ever before.

This kind of degenerative relationship is not uncommon among the elderly in even the happiest marriages, marriage therapists and geriatricians said. But that is small comfort to either the couple in the middle of the maelstrom, or the children who care for them, as evidenced by a number postings on caregiver blogs. As some of the children have wondered there: “Why can’t we all just get along?”

Therapists and others who work with the elderly said the first step to addressing the problem is understanding where it came from.

“A key question is whether the marital bickering is part of a lifelong marital style or a change,” said Dr. Linda Waite, director of the Center on Aging at NORC/University of Chicago. Is it new behavior – or just new to the grown children who are suddenly so deeply enmeshed in their parents’ lives that they are only now noticing that something is amiss?

How much of the problem is really just the marriage style? “Some couples like to fight and argue – it keeps their adrenaline going,” said Dr. Nancy K. Schlossberg, professor emerita of counseling psychology at the University of Maryland and author of “Overwhelmed: Coping with Life’s Ups and Downs.”

Sometimes the best judges of whether there is a problem are outsiders, said Dr. William Dale, chief of geriatrics at the University of Chicago Geriatrics Medicine. Pay attention if someone says, “‘Gee, Mom seems more argumentative or withdrawn than the last time I saw her,’” Dr. Dale advised.

If the tone or severity of the marital tensions seem new, then it is important to find out why. The causes could be mental or physical, doctors say.

On the mental front, increased anger and fighting could be one of the first signs of mild cognitive impairment, a precursor of dementia or Alzheimer’s, in one or both of the spouses, said Dr. Lisa Gwyther, director of the Duke Center for Aging Family Support Program and Associate Professor in the Department of Psychiatry and Behavioral Sciences.

Dr. Dale concurs: “There is good evidence that the earliest signs of cognitive impairment are often emotional changes” — anger, anxiety, depression — “rather than cognitive ones” — memory, abstract thought.

But these early signs of cognitive decline can be so subtle that neither the spouses themselves, or their grown children, recognize them for what they are, Dr. Gwyther said. So husband and wife blame each other for the changes and allow feelings of hurt and resentment to grow.

Withdrawing from activities that used to give them pleasure can be a telltale sign of mild cognitive impairment – and can trigger anger and arguments.

“In one couple, the husband just didn’t want to participate in the holidays — the wife got angry and said he was being lazy and stubborn,” said Dr. Gwyther. But the truth was that his cognitive decline made all the activity overwhelming, and he didn’t want anyone to know that he was anxious about not remembering everyone’s names and embarrassing himself.

Suspicion and paranoia can also accompany mild cognitive decline and precipitate distrust and hurtful accusations. Dr. Gwyther recalled another woman who “called her daughter frantic because she said her husband dropped her at her chemo appointment, went to park the car, and didn’t return to get her.” The woman couldn’t imagine that her husband could possibly have lost his sense of time and direction, Dr. Gwyther added. She took it personally, complaining to her daughter that “your father doesn’t seem to care any more.”

Dr. Dale told of a spouse who accused her mate of infidelity because “she was convinced that when he was out grocery shopping he was really having an affair.”

Hoarding, an early symptom of mild cognitive impairment, can also create tension in a marriage. (For new treatments, see this recent post by my colleague Paula Span.)

When one couple came to a counseling session with Dr. Norman Abeles, emeritus professor of psychology and former director of psychological clinic at Michigan State University, the hoarding spouse finally said, “she did it because she thought that they would run out of money, even though there was enough money to go around.” Dr. Abeles said that incident led to her diagnosis of mild cognitive impairment.

Adding to the confusion, mild cognitive impairment (M.C.I.) comes and goes. “There are good days and bad days, good hours and bad hours,” said Dr. Gwyther. “Alzheimer’s and dementia don’t start on Tuesday — it’s a slow insidious onset.” But the diagnosis is becoming more common: The Institute for Dementia Research and Prevention predicts that 1 in 6 women, and 1 in 10 men, who live past the age of 55 will develop dementia in their lifetime.

“Spouses find it difficult to know when their partner with M.C.I. is acting differently (usually badly) due to the advancing illness or due to ‘willful’ personality issues,” said Dr. Dale, citing a 2007 study in the journal Family Relations exploring the problems this can create for couples.

Blaming is often easier than understanding. Another of Dr. Gwyther’s patients was furious at her husband for not filing their taxes. “He’s a C.P.A.,” she said. “How could we owe back taxes?” It did not occur to her that he might be unable to handle that task — and was too frightened about his deteriorating mental focus to let her know.

But as harmful as mental decline can be for a marriage, it is just part of the equation. Physical ailments – even those that seem completely unrelated to marital relations – “can upset the equilibrium of the marriage,” according to a study in the Canadian Medical Association Journal.

“Most men get angry at what’s happened to them when they get ill, women get angry and scared when he’s not what he used to be — so they fight,” said Dr. Schlossberg.

Chronic illnesses, like diabetes, arthritis and heart disease, can have a strong negative effect on mood, said Dr. Waite, who will soon be publishing a study on the subject. Diabetes is so often accompanied by depression that, Dr. Waite said, “one of my colleagues argues that that it is even part of the disease.”

And ailments can have an effect on a couple’s sex life — which can compound the marital problems, doctors said.

“Diabetes brings on neuropathy,” said Dr. Waite. “That means touching and feeling in sex is not as rewarding.” Without the pleasures of affectionate touching — whether a passing hug at the sink, or more — tensions can build. That’s why, if a couple is having problems with sex, they are more likely to have problems in the relationship — and vice versa, according to a 2007 New England Journal of Medicine study of sex and health among older adults.

Other changes in circumstances — retirement, shifting roles, the loss of autonomy, disparities in health and abilities — can wreak havoc. Losing independence can feel like losing oneself — and if you don’t know who you are any more, how can you know how to relate to your spouse?

“Fighting may come from a misguided notion that you can regain power by asserting it over your spouse,” said Dr. Schlossberg, whose observations are echoed in a 1984 study in the Canadian Journal of Medicine. “It doesn’t work, it’s false power – but they’ll try anything.”

The sheer exhaustion that can come from being the caregiving spouse is also bound to “make them stressed and angry,” said Dr. Waite. Not to mention guilty and resentful — never a prescription for happy marital relations.

“Part of the trap for the caregiver is the idea that you have to do it all, and the guilt you feel when you cannot live up to it,” said Dr. Gordon Herz, a psychologist in private practice in Madison, Wisc. Not surprisingly, resentment can soon follow, Dr. Herz added, because it’s hard to admit to anyone that, “‘this is too much for me.’”

What can outside caregivers — children or other loved ones — do about these golden marriages on the rocks? Should they intervene — or butt out? And can marital therapy help — or is it too late to change?

Share your thoughts and experiences — and tomorrow we’ll try to provide some advice from experts.

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In Europe, a Push for Higher Phone Fees

BERLIN — When the authorities have tinkered with European telecommunications rules, it has usually been to lower prices for consumers, whether through retail price controls on mobile roaming fees or mandatory cuts in regulated interconnection charges.

But this year, to encourage more investment in high-speed broadband networks, regulators are considering helping the biggest operators increase a main source of income: the rent they receive from rivals that lease their landline grids.

The architect of the plan, Neelie Kroes, the European Union’s digital agenda commissioner, has pitched the increases as part of a broader package to stimulate spending while preserving competition and consumer choice.

The plan, however, has alarmed operators that would have to pay the higher charges, like the British mobile operator Vodafone. Vittorio Colao, chief executive of Vodafone, said that the plan to increase the fees collected by former monopolies, including BT, Deutsche Telekom, France Télécom, KPN, Telecom Italia and Telefónica, could lead to a “re-monopolization” of the business.

Mr. Colao said he was worried that landline operators would use the additional revenue to lower their own prices and try to squeeze competitors like Vodafone.

“Increasing the incentive to invest is a good thing,” Mr. Colao said. But now Ms. Kroes must “demonstrate that these new criteria won’t contaminate the competitive arena in Europe,” he said.

Under the plan, the European Commission, the executive arm of the European Union, would begin regulating the fees that mobile operators routinely pay to lease the grids of landline operators.

In much of the world, running telecommunications lines to homes and businesses has traditionally been the domain of a local monopoly, or sometimes a duopoly in the case of telephones and cable television in the United States. Until 1998, countries in the European Union were allowed to maintain national monopolies for this “local loop” to the consumer.

With deregulation, however, the former monopolies were required to unbundle the cost of the local loop and offer it to competitors, thus allowing companies like Vodafone to enter the market.

Despite 14 years of deregulation, and the addition of more than 100 mobile operators in Europe, the former monopolies still supply the majority of fixed-line services in their home countries. In Spain, Telefónica has more than 70 percent of this business.

Until now, these unbundling rates have been set by national regulators, and the average monthly cost per customer in the European Union stands at €8.62, or $11.35. The fee typically makes up a third or more of monthly landline phone bills in Europe and also influences wireless prices because it affects mobile operator costs. The fee ranges from €4.20 in Slovakia to €12.41 in Ireland.

Mrs. Kroes proposed to lower, not raise, unbundling fees in September 2011, to make the old landline networks less profitable for big operators and to encourage them to invest in new networks. But the former monopolies protested, and after personal appeals from executives at big operators, in some cases accompanied by their investors, she reversed course.

Ms. Kroes is proposing that each country within the European Union be required to set its fee within the range of €8 to €10 per month, according to a copy of her proposal obtained by the International Herald Tribune. The new range would most likely require 10 E.U. countries where the fee is currently below this range to raise it, in some cases only slightly, and in others, sharply.

The increases would in all likelihood be passed on to consumers. The rise in fees could be greatest in Eastern Europe, where regulators have been most aggressive in setting low leasing rates to encourage competition. The level of leasing charges could double in Estonia, Latvia, Poland and Slovakia.

Mr. Colao, the Vodafone chief executive, said Ms. Kroes needed to tighten the legal safeguards in her plan to prevent big operators from exploiting access to landline networks.

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10 Afghan Girls Killed in Old Mine Blast; Car Bomb Kills One in Kabul

Parwiz/Reuters

Afghan villagers gathered around the bodies of girls who were killed by an explosion on Monday.

KABUL, Afghanistan — A suicide bomber driving a car packed with explosives targeted the compound of a private military contractor on the eastern outskirts of Kabul on Monday, killing at least one person and injuring at least 15 others, including foreigners, the police said.

In a separate episode, 10 girls were killed in a rural district of eastern Afghanistan on Monday when a roadside bomb exploded while they were collecting firewood, the Afghan police said. The office of the governor of Nangarhar Province said the girls were all between 9 and 11 years old. The Ministry of Education said some were as young as 6.

The Kabul explosion sent a large plume of smoke above the capital on the Jalalabad road, a main thoroughfare leading east out of the city lined with shops, yards and industrial units.

The target was a company called Contrack International, said Gen. Mohammed Dawood Amin, Kabul’s deputy chief of police. Officials said Contrack was a construction maintenance company that provided logistics services for the Afghan Army and police and NATO coalition bases.

“There was a blast, a boom and a wall fell down,” said Roheen Fedai, 19, who said he worked in the company’s call center. Shortly after the blast, he was wandering close to the compound with his hand in a bandage and blood on his face from an eye injury.

The car exploded in a small lane between the company and another compound housing a carton-making factory, blasting down walls and destroying a two-story office.

Barialyia, a security official for Contrack, said the company’s country director was wounded in the explosion. He said five American and South African citizens were among the injured.

Mr. Fedai said Contrack was an American-owned supplier to the Afghan military. Officials here also said the company was American-owned, but the company could not be reached to confirm this or other details about the attack. Its Web site says its headquarters are in McLean, Va., and shows that it has provided services for the United States military in the past.

The compound is close to a NATO base, Camp Phoenix, and other NATO installations. The Taliban claimed responsibility, but a coalition spokesman in Kabul, Lt. Col. Hagen Messer, said the attack did not affect the NATO bases, and there were no coalition casualties.

In the blast in eastern Afghanistan, Hazarat Hussain Masharaqiwal, a spokesman for the police chief of Nangarhar Province, said that the children discovered the unexploded bomb near their village, and that it went off when they hit it with an ax. The explosion also injured a boy who was with them.

The local police said the bomb probably dated from the civil war or even the Soviet occupation of the country.

The United States-led International Security Assistance Force in Afghanistan said the explosion was caused by the accidental triggering of an old land mine, quoting the governor of Chaparhar District in Nangarhar.

In a statement, Gen. John R. Allen, the commander of American and international forces in Afghanistan, said he was saddened by the girls’ deaths. “Over three decades of conflict, Afghanistan became one of the most heavily mined countries on earth,” he said.

Sharifullah Sahak contributed reporting from Kabul, Afghanistan, and Khalid Alokozai from Nangarhar.

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As Gold Is Spirited Out of Afghanistan, Officials Wonder Why

Zalmai for The New York Times

A Kabul jewelry shop. Officials are concerned about gold being flown out of Afghanistan.

KABUL, Afghanistan — Packed into hand luggage and tucked into jacket pockets, roughly hewed bars of gold are being flown out of Kabul with increasing regularity, confounding Afghan and American officials who fear money launderers have found a new way to spirit funds from the country.

Most of the gold is being carried on commercial flights destined for Dubai, according to airport security reports and officials. The amounts carried by single couriers are often heavy enough that passengers flying from Kabul to the Persian Gulf emirate would be well advised to heed warnings about the danger of bags falling from overhead compartments. One courier, for instance, carried nearly 60 pounds of gold bars, each about the size of an iPhone, aboard an early morning flight in mid-October, according to an airport security report. The load was worth more than $1.5 million.

The gold is fully declared and legal to fly. Some, if not most, is legitimately being sent by gold dealers seeking to have old and damaged jewelry refashioned into new pieces by skilled craftsmen in the Persian Gulf, said Afghan officials and gold dealers.

But gold dealers in Kabul and current and former Kabul airport officials say there has been a surge in shipments since early summer. The talk of a growing exodus of gold from Afghanistan has been spreading among the business community here, and in recent weeks has caught the attention of Afghan and American officials. The officials are now puzzling over the origin of the gold — very little is mined in Afghanistan, although larger mines are planned — and why so much appears to be heading for Dubai.

“We are investigating it, and if we find this is a way of laundering money, we will intervene,” said Noorullah Delawari, the governor of Afghanistan’s central bank. Yet he acknowledged that there were more questions than answers at this point. “I don’t know where so much gold would come from, unless you can tell me something about it,” he said in an interview. Or, as a European official who tracks the Afghan economy put it, “new mysteries abound” as the war appears to be drawing to a close.

Figuring out what precisely is happening in the Afghan economy remains as confounding as ever. Nearly 90 percent of the financial activity takes place outside formal banks. Written contracts are the exception, receipts are rare and statistics are often unreliable. Money laundering is commonplace, say Western and Afghan officials.

As a result, with the gold, “right now you’re stuck in that situation we usually are: is there something bad going on here or is this just the Afghan way of commerce?” said a senior American official who tracks illicit financial networks.

There is reason to be suspicious: the gold shipments track with the far larger problem of cash smuggling. For years, flights have left Kabul almost every day carrying thick wads of bank notes — dollars, euros, Norwegian kroner, Saudi Arabian riyals and other currencies — stuffed into suitcases, packed into boxes and shrink-wrapped onto pallets. At one point, cash was even being hidden in food trays aboard now-defunct Pamir Airways flights to Dubai.

Last year alone, Afghanistan’s central bank says, roughly $4.5 billion in cash was spirited out through the airport. Efforts to stanch the flow have had limited impact, and concerns about money laundering persist, according to a report released last week by the United States Special Inspector General for Afghanistan Reconstruction.

The unimpeded “bulk cash flows raise the risk of money laundering and bulk cash smuggling — tools often used to finance terrorist, narcotics and other illicit operations,” the report said. The cash, and now the gold, is most often taken to Dubai, where officials are known for asking few questions. Many wealthy Afghans park their money and families in the emirate, and gold dealers say more middle-class Afghans are sending money and gold — seen as a safeguard against economic ruin — to Dubai as talk of a postwar economic collapse grows louder.

But given Dubai’s reputation as a haven for laundered money, an Afghan official said that the “obvious suspicion” is that at least some of the apparent growth in gold shipments to Dubai is tied to the myriad illicit activities — opium smuggling, corruption, Taliban taxation schemes — that have come to define Afghanistan’s economy.

There are also indications that Iran could be dipping into the Afghan gold trade. It is already buying up dollars and euros here to circumvent American and European sanctions, and it may be using gold for the same purpose.

Yahya, a dealer in Kabul, said other gold traders were helping Iran buy the precious metal here. Payment was being made in oil or with Iranian rials, which readily circulate in western Afghanistan. The Afghan dealers are then taking it to Dubai, where the gold is sold for dollars. The money is then moved to China, where it was used to buy needed goods or simply funneled back to Iran, said Yahya, who like many Afghans uses a single name.

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Dr. William F. House, Inventor of Cochlear Implant, Dies

Dr. William F. House, a medical researcher who braved skepticism to invent the cochlear implant, an electronic device considered to be the first to restore a human sense, died on Dec. 7 at his home in Aurora, Ore. He was 89.

The cause was metastatic melanoma, his daughter, Karen House, said.

Dr. House pushed against conventional thinking throughout his career. Over the objections of some, he introduced the surgical microscope to ear surgery. Tackling a form of vertigo that doctors had believed was psychosomatic, he developed a surgical procedure that enabled the first American in space to travel to the moon. Peering at the bones of the inner ear, he found enrapturing beauty.

Even after his ear-implant device had largely been supplanted by more sophisticated, and more expensive, devices, Dr. House remained convinced of his own version’s utility and advocated that it be used to help the world’s poor.

Today, more than 200,000 people in the world have inner-ear implants, a third of them in the United States. A majority of young deaf children receive them, and most people with the implants learn to understand speech with no visual help.

Hearing aids amplify sound to help the hearing-impaired. But many deaf people cannot hear at all because sound cannot be transmitted to their brains, however much it is amplified. This is because the delicate hair cells that line the cochlea, the liquid-filled spiral cavity of the inner ear, are damaged. When healthy, these hairs — more than 15,000 altogether — translate mechanical vibrations produced by sound into electrical signals and deliver them to the auditory nerve.

Dr. House’s cochlear implant electronically translated sound into mechanical vibrations. His initial device, implanted in 1961, was eventually rejected by the body. But after refining its materials, he created a long-lasting version and implanted it in 1969.

More than a decade would pass before the Food and Drug Administration approved the cochlear implant, but when it did, in 1984, Mark Novitch, the agency’s deputy commissioner, said, “For the first time a device can, to a degree, replace an organ of the human senses.”

One of Dr. House’s early implant patients, from an experimental trial, wrote to him in 1981 saying, “I no longer live in a world of soundless movement and voiceless faces.”

But for 27 years, Dr. House had faced stern opposition while he was developing the device. Doctors and scientists said it would not work, or not work very well, calling it a cruel hoax on people desperate to hear. Some said he was motivated by the prospect of financial gain. Some criticized him for experimenting on human subjects. Some advocates for the deaf said the device deprived its users of the dignity of their deafness without fully integrating them into the hearing world.

Even when the American Academy of Ophthalmology and Otolaryngology endorsed implants in 1977, it specifically denounced Dr. House’s version. It recommended more complicated versions, which were then under development and later became the standard.

But his work is broadly viewed as having sped the development of implants and enlarged understanding of the inner ear. Jack Urban, an aerospace engineer, helped develop the surgical microscope as well as mechanical and electronic aspects of the House implant.

Karl White, founding director of the National Center for Hearing Assessment and Management, said in an interview that it would have taken a decade longer to invent the cochlear implant without Dr. House’s contributions. He called him “a giant in the field.”

After embracing the use of the microscope in ear surgery, Dr. House developed procedures — radical for their time — for removing tumors from the back portion of the brain without causing facial paralysis; they cut the death rate from the surgery to less than 1 percent from 40 percent.

He also developed the first surgical treatment for Meniere’s disease, which involves debilitating vertigo and had been viewed as a psychosomatic condition. His procedure cured the astronaut Alan B. Shepard Jr. of the disease, clearing him to command the Apollo 14 mission to the moon in 1971. In 1961, Shepard had become the first American launched into space.

In presenting Dr. House with an award in 1995, the American Academy of Otolaryngology-Head and Neck Surgery Foundation said, “He has developed more new concepts in otology than almost any other single person in history.”

William Fouts House was born in Kansas City, Mo., on Dec. 1, 1923. When he was 3 his family moved to Whittier, Calif., where he grew up on a ranch. He did pre-dental studies at Whittier College and the University of Southern California, and earned a doctorate in dentistry at the University of California, Berkeley. After serving his required two years in the Navy — and filling the requisite 300 cavities a month — he went back to U.S.C. to pursue an interest in oral surgery. He earned his medical degree in 1953. After a residency at Los Angeles County Hospital, he joined the Los Angeles Foundation of Otology, a nonprofit research institution founded by his brother, Howard. Today it is called the House Research Institute.

Many at the time thought ear surgery was a declining field because of the effectiveness of antibiotics in dealing with ear maladies. But Dr. House saw antibiotics as enabling more sophisticated surgery by diminishing the threat of infection.

When his brother returned from West Germany with a surgical microscope, Dr. House saw its potential and adopted it for ear surgery; he is credited with introducing the device to the field. But again there was resistance. As Dr. House wrote in his memoir, “The Struggles of a Medical Innovator: Cochlear Implants and Other Ear Surgeries” (2011), some eye doctors initially criticized his use of a microscope in surgery as reckless and unnecessary for a surgeon with good eyesight.

Dr. House also used the microscope as a research tool. One night a week he would take one to a morgue for use in dissecting ears to gain insights that might lead to new surgical procedures. His initial reaction, he said, was how beautiful the bones seemed; he compared the experience to one’s first view of the Grand Canyon. His wife, the former June Stendhal, a nurse, often helped.

She died in 2008 after 64 years of marriage. In addition to his daughter, Dr. House is survived by a son, David; three grandchildren; and two great-grandchildren.

The implant Dr. House invented used a single channel to deliver information to the hearing system, as opposed to the multiple channels of competing models. The 3M Company, the original licensee of the House implant, sold its rights to another company, the Cochlear Corporation, in 1989. Cochlear later abandoned his design in favor of the multichannel version.

But Dr. House continued to fight for his single-electrode approach, saying it was far cheaper, and offered voluminous material as evidence of its efficacy. He had hoped to resume production of it and make it available to the poor around the world.

Neither the institute nor Dr. House made any money on the implant. He never sought a patent on any of his inventions, he said, because he did not want to restrict other researchers. A nephew, Dr. John House, the current president of the House institute, said his uncle had made the deal to license it to the 3M Company not for profit but simply to get it built by a reputable manufacturer.

Reflecting on his business decisions in his memoir, Dr. House acknowledged, “I might be a little richer today.”

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