Tuesday, April 8, 2014
Last September we noted the kick-off of the Stanford Center on Longevity's world-wide Design Challenge that encouraged teams to tackle the need for "solutions that help keep people with cognitive impairments independent as long as possible." In March, PBS News Hour had a nice piece on the partnership that launched the competition.
The latest news is that 7 teams are finalists from among 52 entries from 15 countries. The final phase of the competition will take place on April 10. As explained by Stanford's news release:
"They are coming to Stanford to make their final pitches for a $10,000 first prize and connections to industry leaders and investors. There will be talks by a number of distinguished speakers, a panel of Silicon Valley investors, and the announcement of next years’ challenge. Join us for what should be a great day of learning and networking."
Saturday, April 5, 2014
Ralph Schwanbeck feared that his 87-year-old wife, Dorothy, might balk at donning headphones for the first time in her life, but her broad smile proved that the iPod was playing her songs.
Dorothy, who has Parkinson's disease, gently tapped her toes a few times while listening to some of her favorite tunes recently at Hillview Health Care Center in La Crosse. Hillview is one of 100 nursing homes statewide certified to participate in a Wisconsin Department of Health Services program to help residents with Alzheimer's disease and related dementias. Titled the Wisconsin Music and Memory Initiative, the program employs iPods with personalized playlists to rekindle residents' memories with familiar music, as well as lift their spirits and improve their interaction with family members, other residents and staffers. The program provides each nursing home with 15 iPods, but Hillview sees such promise that it also bought one and invites people to donate new or used iPods. Even though Hillview began the program just recently, results for Dorothy already were beginning to show.
Wednesday, April 2, 2014
Via the Alzheimer's Association:
We have known that women are the epicenter of Alzheimer's disease - making up the majority of both people living with the disease and caregivers. Not only are 3.2 million women living with Alzheimer's, women are also at the epicenter of caregiving for someone with the disease. The Alzheimer's Association's new 2014 Alzheimer's Disease Facts and Figures report shows women have a 1 in 6 chance of developing Alzheimer's, while men have a 1 in 11 chance. As real a concern as breast cancer is to women's health, women in their 60s are about twice as likely to develop Alzheimer's over the rest of their lives as they are to develop breast cancer.
A new Alzheimer's Association women's initiative has launched in conjunction with the Facts and Figures report. Realizing the impact Alzheimer's has on women - and the impact women can have when they work together - we ask women to share why their brain matters and how they can use it to end Alzheimer's at alz.org/mybrain.
Sunday, March 30, 2014
Last fall, our Elder Law Prof Blog reported on the available of a MOOC (Massive Open On-Line Course) offered by John Hopkins School of Nursing on "Care of Elders with Alzheimer's Disease and other Major Neurogonitive Disorders." Did any of our readers participate? We welcome reports on your reactions to the experience.
Now there's a another MOOC opportunity, this time from the University of Tazmania on "Understanding Dementia." The 9-week course is described as "building on the latest in international research on dementia." And, true to the spirit of MOOCs, it is free and open to anyone to register, here. The course begins Monday, March 31 -- so hurry to register.
Friday, March 28, 2014
This semester I'm teaching Contracts, which always provides interesting opportunites to introduce "Elder Law" concerns in a traditional course.
This week I offered a not-so-hypothetical fact pattern, where Grandmother deeds house to Grandchild, in exchange for Grandchild's "promise to care for Grandma for the rest of her life." Whenever I use this hypo, I pick one of a number of reasons the agreement does not work out as planned, such as the individuals don't get along with each other, grandchild gets pregnant or ill, etc. This week's reason was "Grandma needs more specialized care" but cannot afford it because she's given away her primary resource. Grandchild doesn't want to sell the house, now that it is "hers," and she doesn't want to take out a mortgage.
I ask the students to brainstorm Grandmother's options. Almost always, someone suggests Medicaid, and we talk about whether Medicaid will provide adequate assistance and whether there are potential barriers to eligibility for public benefits, such as the five-year look back period.
Students sometimes suggest Grandmother is subject to "undue influence," which if proven would be grounds for potential rescission. Good job! Except that I am usually careful in my hypo not to make Grandchild overtly manipulative. And in truth, many of these arrangements begin more because of the desires of the aging individual, than because of any greed on the part of the younger person. We also explore "incapacity" and "duress" as possible grounds for rescission.
This week, students also suggested "failure of consideration" as grounds for rescission. There is an interesting line of cases, perhaps a hybrid of Property and Contract law, that treats "support deeds" as a specific analysis, potentially justifying relief. Examples include:
- Gilbert v. Rainey, 71 SW. 3d 66 (Ark. Ct. App. 2002), permitting mother to rescind deed for failure of consideration, and admitting mother's parol evidence to show daughter promised life care in exchange for the conveyance of the home, to show that conveyance was not a completed gift;
- Frasher v. Frasher, 249 S.E. 2d 513 (W.Va. 1978), granting cancellation of deed from grandparents to grandchildren, on the grounds that where discord arises between the parties to a "support deed" between an aged grantor and a younger family member, the property should be restored "if it can be done without injustice" to the younger family member.
After class was over, some of my students stopped by to chat, offering variations on the hypothetical, sometimes from examples within their own extended families. In both of the sample cases above, the court attaches special meaning to the concept of "support deeds" going from older to younger generation, but most of the cases along this line are fairly old. The fact that my students were offering modern variations on the fact pattern suggests there may be good reason to revisit this area of the law.
Perhaps any resurgence in this topic is another sign of our "aging" times. So, that leads to my question, does your state recognize failure of consideration, tied to "support deeds," as grounds for rescission of a conveyance?
Thursday, March 27, 2014
Occasionally on this Blog we post to studies suggesting cutting edge scientific developments connected to Alzheimer's. For example, last October, our colleague Professor Dayton, provided a link to a study in England described as a possible "breakthrough" in Alzheimer's research related to misfolded proteins in the brain. John O'Connor, the executive director for McKnight's Long-Term Care News, recently offered his own reaction to such news, following release of a different study:
"Here we go again: This week saw the release of yet another breathless study claiming the cure for Alzheimer's disease is getting closer — maybe.
The latest incantation is a report in Nature Genetics. This entry touts an international study of the disease that may help us unlock a cure. Unless, of course, it doesn't.
It seems like we get treated to at least one or two of these “important breakthrough” studies every month, sometimes more. And the plot seldom varies: Earnest investigators working countless hours have issued a report that may bring us closer to a cure. Then, tucked somewhere in the back is a mention that, ahem, more research is needed."
As with Mr. O'Connor, I suspect many of us have experienced "breakthrough fatigue" in the area of Alzheimer's research. Nonetheless, I am going to point to another study, this time suggesting a blood test targeting biomarkers that "may be sensitive to early neurodegeneration of preclinical Alzheimer's disease," and thus predictive of "either amnestic mild cognitive impairment or Alzheimer's disease within a 2-3 year time frame." The report on "Plasma Phospholipids Identify Antecedent Memory Impairment in Older Adults" is in the March 2014 issue of the journal Nature Medicine and despite the somewhat intimidating title, it makes for interesting reading.
But my real question is not about the value of the study, or as John O'Connor's essay suggests, concerns about the potential for hype to generate false hope, but whether many would actually be horrified by a predictor of future cognitive impairment within 2 to 3 years, even (especially?) one with "over 90% accuracy." I can think of several people I've known who worried about their "failing memory," sometimes for years, but who expressly rejected seeing a specialist for testing. Without a solution, such tests might be the ultimate example of the unfunny joke: Do you want to hear the good news or the bad news first? We know what's going to happen to you -- but you aren't going to like it.
Tuesday, March 25, 2014
William and Mary Law School student Elizabeth Hill takes on the challenge of discussing sex and seniors in her Student Note, "We'll Always Have Shady Pines: Surrogate Decision-Making Tools for Preserving Sexual Autonomy in Elderly Nursing Home Residents" for the Winter 2014 issue of the William and Mary Journal of Women and the Law. She concludes:
"With changes to state law to expand the tool of power of attorney, residents who want to retain autonomy in decisions about their bodies and relationships could employ surrogate decision-making tools like durable powers of attorney and advance healthcare directives to ensure that they are able to participate in and enjoy sexual activity even after the have lost the capacity to consent and even if their families disapprove of the activity. Perhaps the most difficult aspect of adopting such a mechanism would be putting aside our personal and preconceived notions about sexual conduct in order to allow others to experience a little happiness in an otherwise gloomy setting."
The title for the article, alluding to Humphrey Bogart's famous line in Casablanca, is a clever introduction to a sensitive topic.
Monday, March 24, 2014
- Advocacy Centre for the Elderly and Dykeman Dewhirst O’Brien LLP: Health Care Consent and Advance Care Planning: Standards and Supports
- ARCH Disability Law Centre: Decisions, Decisions: Promoting and Protecting the Rights of Persons with Disabilities Who Are Subject to Guardianship
- Canadian Centre for Elder Law: Understanding the Lived Experience of Supported Decision-making in Canada - A Study Paper
- Dr. Bonnie Lashewicz: Understanding and Addressing Voices of Adults with Disabilities Within Their Family Caregiving Contexts: Implications for Legal Capacity, Decision-making and Guardianship
Saturday, March 22, 2014
Wednesday, March 19, 2014
Every 67 seconds someone in the United States develops Alzheimer's disease. More than 5 million Americans are living with the disease. Learn the facts. Help wipe out Alzheimer's disease.
I spent most of our recent spring break in Arizona with my parents and sister (and trying to thaw my frozen bones). I had time to visit friends, some I haven't seen in decades, and often I was tempted to give a rueful chuckle. We're all in the same age range -- and several of us are searching for ways to help aging parents. With friends who have a parent with dementia, as soon as they find out that much of my work now focuses on "elder law," I would get what I've come to think of as "the question."
What's the question? "Is it inevitable that I too will develop dementia?" Of course, I'm a law professor, not a doctor. My friends are asking the wrong person.
But, then I noticed that several of my friends were reading the same book. The book is "100 Simple Things You Can Do to Prevent Alzheimer's and Age-Related Memory Loss," by Jean Carper, a well-respected medical journalist. One friend loaned me a copy. It was first published in 2010. I asked friends what they liked about the book, and more than one mentioned the "single idea" format for chapters, short enough to keep the reader on task, while sufficiently detailed to convince the reader why that "tip" just might make sense.
Some of the 100 "things" are, I hope, mostly an affirmation of common sense, such as Chapter 17's "Count Calories" and Chapter 20's "Control Bad Cholesterol." Occasionally a chapter strikes me as a bit trendy, such as the admonition in Chapter 22 to "Go Crazy For Cinnamon." But quite a few topics and explanations were either surprising, intriguing, or both, including Chapter 3's recommendation to "Check Out Your Ankle." The author explains how low blood flow in your foot, measurable by an ankle-brachial index (ABI) test, can point to looming troubles for the brain.
Happy reading and good luck adapting the tips to your life. Remember, with 100 recommendations to read, evaluate, and, as appropriate, embrace, it doesn't hurt to start "young."
Monday, March 17, 2014
The Centre for Ageing Research and Development in Ireland (CARDI) is a great resource for comparative research, capturing a wide range of articles and projects in Europe, as well as the latest research grants in the north and south of Ireland.
In one of the recent reports linked by CARDI, "A National Survey of Memory Clinics in the Republic of Ireland," researchers are critical of the lack of clear standards for diagnosis, treatment and collection of data on dementia, and point to potential weaknesses observed in a national system of Memory Clinics (MCs) in the Republic of Ireland (ROI), noting the potential for such problems to exist on a broader basis:
"Although this is an Irish-based study, our findings raise several important questions pertinent to many countries around the world currently developing and expanding diagnostic and postdiagnostic services to address the challenge of dementia. First, what type of specialist services do MCs offer and what are their core aims and objectives? Are MCs concerned with offering a more correct diagnosis than what might otherwise be available through generalist services? Are they committed to providing earlier diagnoses and interventions in more unusual cases (including memory problems that are reversible) and if this is the case, is a waiting time of up to four months acceptable? In the ROI, GPs [general practitioners] are permitted to initiate cholinesterase inhibitors for patients diagnosed with dementia, but would it be preferable if the prescription of such drugs was confined to MCs or other specialists involved in dementia diagnosis? What role do MCs play with respect to the education and training of primary care and other allied health professionals? Should this role be confined to only the larger longer established clinics that become Centers of Excellence and review only few and very rare cases?"
Do we have any systemic approach to diagnosis, treatment and data collection on dementia in the United States?
Friday, March 14, 2014
The Third World Congress on Adult Guardianship will be in Washington DC May 28-30. Registration is now underway. Anyone interested in national and international developments in the realm of guardianship should attend this conference, which features speakers from 21 countries/six continents.
Information about the Congress, and registration materials, are available via the main website. My advice: this is one event you don't want to miss!
March is Developmental Disabilities Awareness Month and to mark the occasion, The Arc is inviting everyone with intellectual and developmental disabilities to make plans to go out somewhere in public on Saturday, March 29 to break down social barriers, dispel myths and raise awareness.
Please share this message and encourage those you know with I/DD, their colleagues, friends and families to make plans to hit the movies, the park, a local shopping center or restaurant for a day out and maybe spark some conversation in the process.T
Check the landing page on thearc.org with more information and launch an email and social media campaign to encourage folks to join in. Plus, we have a couple of guest bloggers lined up for March to share their personal experiences on the topic of social barriers on The Arc’s blog (blog.thearc.org). Spread the word using the hashtag #DDAware on social media during the month of March. And, follow us on Facebook or Twitter where we will be sharing photos and stories from everyone’s March 29 activities.
Wednesday, March 5, 2014
The American Geriatrics Society and the American Board of Internal Medicine Foundation have joined in a venture called "Choosing Wisely," and recently issued "Five Things Physicians and Patients Should Question."
The items are intended to stimulate more thoughtful decision making, especially in dementia care, and address diet, restraints, and use of screening tests. Two items that hit home include:
- Don't prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.
- Don't prescribe any medication without conducting a drug regimen review.
This "Five Things" list was actually the second set of "Choosing Wisely" recommendations. Here's a link to the important first list, which includes the concern about off-label prescriptions of antipsychotic medications to treat symptoms in dementia, a topic that has also been the subject of major whistleblower cases and settlements involving the pharmaceutical industry.
Tuesday, February 25, 2014
One of my frequent travel routes is to drive between Carlisle and Baltimore, in order to take direct flights from BWI to Phoenix, where my parents live. Usually these drives are in the middle of the night, as I try to avoid traffic by scheduling very early or late flights. One positive aspect of this travel is the time to discover interesting radio programs; there is something about listening to radio in the dark that allows one to hear more clearly. Last week, I lingered in the car after reaching the long-term airport parking, to listen to the end of an especially effective interview.
On Point with Tom Ashbrook, was hosting Kimberly Williams-Paisley who spoke movingly about her family as they coped with her mother's early onset of a form of dementia, diagnosed at age 61. For those of you who enjoy either movies or music, you might recognize Kimberly as an actress from Father of the Bride (she was the daughter driving Steve Martin to wit's end) and Nashville, or as the wife of country music star Brad Paisley. Also featured on the program was a clinical social worker, Darby Morhardt, who is an associate professor at the Cognitive Neurology and Alzheimer’s Disease Center at Northwestern University’s Feinberg School of Medicine.
The program was very thoughtful and emotional, but for me the most compelling words came from Kimberly's father, Gurney Williams.
This is a man deeply in love with his wife and also deeply affected by her condition. At first he tried to hide her diagnosis, but over time, this became more and more difficult. Mr. Williams describes how he finally came to terms with the need for help -- and the need for more than family help -- when his children staged a bit of an intervention. They asked him to recognize that his wife's condition, which in her case included confusion, mood swings, anger and -- at times -- violence, was more than they could cope with in the home. They were worried about their mother, but even more devastated by "losing" their father as he struggled to care for her. With the family's help, he finally made the difficult decision to place his wife in a formal care setting.
And it was during his description of the journey, that I heard the words I've also heard many times from friends, family, students and clients. "I promised my loved one I would never put her in one of those places." I have come to recognize this promise as completely well-intentioned, but also potentially dangerous for all involved.
Listening to Mr. Williams and Kimberly, you could tell formal care was the right decision and they were able to find the right kind of care facility for their loved one. And it was a decision that allowed all of them to find a new way to express their love and devotion to her, while also providing her with a supportive, safe environment. Kimberly talks about how she stopped talking about her mother in the past tense, rediscovered her and how they created a new, valuable relationship. Their story has a happy evolution, which, of course, is different than a happy ending.
One of the reasons I was so affected by listening to Mr. William's words, was that I was on my way to the airport to visit my father -- to see him for the first time -- after his transfer to a dementia-care community. All of my fears and hopes were bound up in my listening. On arriving in the airport I went directly to a shop and bought a copy of the March issue of Redbook Magazine, which carried the story by Kimberly Williams-Paisley that led to the invitation for her and her father to be guests on the On Point program. I read and re-read "How I Faced My Mother's Dementia" on the plane -- and shared her words with my mother when I arrived.
I suspect I might write more about my own evolution with my father. Right now it is easier for me to recommend the article, and to say the podcast of the On Point show is even better than the article.
Wednesday, February 12, 2014
Peter Strauss, Co-Director of the Elder Law Clinic at New York Law School, leads off his school's recent Law Review symposium by reminding us of a powerful early piece published in 1983 by Marion Roach. She recounted the first moments when she realized her mother her mother "might be going mad." She went on to explore her mother's Alzheimer's and the family's struggle in her well-regarded memoir, Another Name for Madness.
Professor Strauss' Introduction opens the symposium issue on the theme of Freedom of Choice at the End of Life: Patients' Rights in a Shifting Legal and Political Landscape. Videos of the presentations are available here.
Sunday, February 9, 2014
Recently an individual contacted me with a fact pattern to present on our Blog, a variation on what we've written about in the past. Here are the basics. I've assigned some gender roles to make the fact pattern easier to follow:
The daughter of an older parent wants to know whether she has a legal "duty" to interfere with her brother's role in the life of their parent, where it appears the brother is failing to either apply for Medicaid or otherwise pay the parent's rehabilitation facility. The parent is not unhappy with the son's actions (or rather, inaction), and in fact declined to give power of attorney to the daughter, even when told of a likely "eviction" for nonpayment of the bill. The parent has mostly recovered from the medical crisis that triggered the need for care -- and just wants to go home. Parent has made it clear to daughter that her help is "unnecessary."
The complication is the size of the unpaid bill, more than $100,000. Apparently the care facility, approved to receive Medicare and Medicaid, is now demanding that the daughter pay the bill. Apparently no one applied for Medicaid and it is unclear whether Medicare ever paid. Daughter doesn't know much about her parent's income, but assumes it is limited and probably the only asset is a house, where the widowed parent lives when not in a hospital or in a care facility, and where the brother also resides.
The rehab facility is in Pennsylvania, home to "filial support" laws that have been enforced against adult children, with or without evidence of fault on the part of the child who is sued. Under Pennsylvania's law, those with statutory standing to pursue a support claim include a "person" who has provided care or maintenance, and that has been interpreted to include residential care facilities. We've discussed tough filial support decisions before on this Blog, including Health Care & Retirement Corp. of America, v. Pittas, (Pa. Super. Ct. 2012).
Thus, a lawyer is probably going to have to break the bad news to the daughter that the facility arguably has a potentially viable claim under 23 Pa.C.S.A. Section 4603. Daughter would appear to have some equitable defenses, including laches, but nothing that is expressly provided in the Pennsylvania statute. But who can afford to defend such a case? The facility appears to be using the child's potential liability under filial support laws to insist the daughter take action, either to obtain a guardianship or other order that would permit her (force her?) to apply for Medicaid -- and the threat may work. The longer she waits, the tougher it will be to get sufficient retroactive coverage. But in this instance, it is not clear whether the parent's capacity is impaired, or whether the parent is simply following a long pattern, even if unwise, of preferring one child's "help" over the other.
The moral question of "Am I my brother's keeper," becomes a Family Keeper's Dilemma, when you add in the third part of the triangle, a parent in need of care or protection, against their will. And the moral question becomes a legal liability question, when a filial support law that permits third-party suits is involved.
For another Family Keeper's Dilemma, see the Washington Court of Appeals' January 14 decision, "published in part," in the case of In re Knight, addressing the level of proof required for one son to obtain a Vulnerable Adult Protection Order, to prevent his brother, with a mental health history and a criminal record, from continuing to live with or near their 83-year-old mother. The mother opposed the protection order.
Thursday, February 6, 2014
Via NBC News:
Every Saturday at Casa Maravilla, a housing development for seniors in Chicago, dozens of older Latinos gather to dance and, they hope, help preserve their memory. At twice-weekly practices, they step in sync in promenade-like moves to danzón, the slow and elegant musical genre that’s popular in Mexico. Or, they swish their hips and twist through each others’ arms to more energetic salsa. The dancers are part of the Latino Alzheimer’s & Memory Disorders Alliance, or LAMDA, which started “Bailando por la Salud” (Dancing for Health) to inspire Latinos who are uncomfortable with other forms of exercise to get fit and healthier -- which in turn may help stave off Alzheimer’s and other memory loss conditions.
Read more at NBC News.
Wednesday, February 5, 2014
An important new book, Sexuality and Dementia: Compassionate & Practical Strategies for Dealing with Unexpected or Inappropriate Behaviors, published in December 2013, offers a physician's candid assessment of a topic often discussed, if at all, only in hushed tones.
Reading the first chapter called to mind a colleague in aging studies, a nurse, who related to me how a tearful woman once asked her how to hire a prostitute, as her husband was in the mid-stages of dementia and constantly wanted sex. The wife as the home caregiver was, in a word, exhausted. This book recognizes that a wide range of sexual behaviors often accompany dementia. Sexual agression is sometimes even a sign that something has changed in the individual's cognitive functioning, only later recognized as an early step in the process of dementia.
The author, Geriatric Neuropsychiatrist Douglas Wornell, is quite critical of the medical profession's approach -- or rather a frequent failure to even discuss -- the topic. Dr. Wornell observes that "to date, patients and their partners have been virtually abandoned by an entire medical system that has provided little to help them with sexuality as it relates to dementia. Considering the numbers of people affected -- tens of thousands of people in my practice alone -- that abandonment is nothing more than shocking."
The book is written in plain terms, covering everything from the "neurobiology of sex and dementia" to the potential for medication to stimulate -- or alleviate -- the condition, while also discussing the impact of the behaviors in the home and in more formal care settings.