Sunday, January 25, 2015

How Do You Tell Family You Have Alzheimer's?

NPR's All Things Considered began a series on January 24th that follows Greg O'Brien's journey with early-onset Alzheimer's, beginning with his diagnosis at age 59.  There is lots of important stuff here, including the need for family dialogue and understanding.  One dialogue is between the father and son, about why it was important for the son to serve as his  dad's agent under a Power of Attorney. 

Here's an excerpt from O'Brien's powerful account:

"How do you tell your kids that you got Alzheimer's? It sucks.

 

I had planned this family meeting, so all the kids were home and we're going to go out to dinner. I knew I had to talk beforehand.So I'm in the bathroom, you know I felt a little bit like Luca Brasi in The Godfather, practicing my speech. 'On the day of your daughter's wedding....'

 

I could hear, 'Daddy,where are you?' So I came out and I went over the fact that their great-grandfather, my grandfather, had died of Alzheimer's and my mother, which they knew. And now it's come for me...."

To read or listen to the series on public radio or podcast, follow the NPR links here.  O'Brien also has a book, On Pluto - Inside the Mind of Alzheimer's.

January 25, 2015 in Cognitive Impairment, Dementia/Alzheimer’s, Estates and Trusts | Permalink | Comments (0) | TrackBack (0)

Thursday, January 22, 2015

Invisible Men and Women - and Lessons from One Who "Awoke"

If you have a loved one with dementia, particularly if you have watched him or her lose the power to communicate with words, perhaps you have wondered, what are they thinking?  What are they hearing when you talk with them? Are they happy?  Sad? Is confusion the dominant, or only, feeling? 

You sometimes get hints of how they feel, including recognition they may feel profoundly trapped.  I knew one man who, when he could not find the words, would shake his head and howl.  I knew one woman who, when she was younger, used to have clever catch-phrases. By the time she was in her 80s, she had lost the ability to say a favorite phrase but she would say two words -- "Head up"--  over and over. She wanted you to help her complete the phrase.  Her caregivers did not know that she had given hundreds of children horseback riding lessons, and misunderstood her words as a warning, perhaps motivated by paranoia. But, as one of her former students, when I heard her say "Head up" during my visit, I responded -- almost automatically -- with "Heels down." It is an equestrian's mantra for balanced riding.  And she smiled as if we had just completed reciting the Gettysburg Address together. 

With that background, I was captivated by a recent public radio broadcast, now available on an Invisibilia podcast, about the "Locked-In Man."  Following an illness and a coma as a child, Martin Pistorius began to "awaken" during his teens,  but for more than 10 additional years he was unable to talk, or even to signal to people caring for him -- or abusing him -- that he was "aware" of what was happening. 

Imagine being trapped in front of reruns of  "Barney" (television's purple dinosaur) day after day after day, for year after year.  I know a senior care facility that seems to have the "King and I" playing on a television around the clock.  Could Yul Brynner's singing be just as much torture as Barney's for someone who is unable to say "not again?"

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January 22, 2015 in Cognitive Impairment, Dementia/Alzheimer’s, Health Care/Long Term Care | Permalink | Comments (0) | TrackBack (0)

Wednesday, January 21, 2015

VSED + Dementia Raise New Questions About Respect for End-of-Life Decisions

A new acronym, VSED, is emerging in discussions of end-of-life decision making.  It refers to Voluntarily Stopping Eating and Drinking. However, what happens when such a plan is combined with increasing dementia? 

As addressed in Paula Span's thoughtful piece for The New York Times' "The New Old Age," it may not be possible to ensure such a plan will be honored, at least not under the existing law of most states. Consider the following example:

"Like many such documents, [Mr. Medalie's Advance Directive] declares that if he is terminally ill, he declines cardiopulmonary resuscitation, a ventilator and a feeding tube. But Mr. Medalie’s directive also specifies something more unusual: If he develops Alzheimer’s disease or another form of dementia, he refuses 'ordinary means of nutrition and hydration.' A retired lawyer with a proclivity for precision, he has listed 10 triggering conditions, including 'I cannot recognize my loved ones' and 'I cannot articulate coherent thoughts and sentences.' 

   

If any three such disabilities persist for several weeks, he wants his health care proxy — his wife, Beth Lowd — to ensure that nobody tries to keep him alive by spoon-feeding or offering him liquids. VSED, short for 'voluntarily stopping eating and drinking,' is not unheard-of as an end-of-life strategy, typically used by older adults who hope to hasten their decline from terminal conditions. But now ethicists, lawyers and older adults themselves have begun a quiet debate about whether people who develop dementia can use VSED to end their lives by including such instructions in an advance directive...."

For more, continue reading  "Complexities of Choosing End Game for Dementia."  Thanks to Elder Law Attorney Morris Klein for sharing this good article.

 

January 21, 2015 in Advance Directives/End-of-Life, Cognitive Impairment, Dementia/Alzheimer’s, State Cases, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)

Monday, January 19, 2015

Should Right-To-Know Law Permit Access to State Retirees' Names & Addresses?

If you were retiring, would you want marketers of insurance products and funeral services -- or similar products -- obtaining your name and address from your former employer? Pennsylvania's Right-to-Know Law could be permitting just such access to information on a large number of state retirees. 

In a decision issued January 9, 2015, the Commonwealth Court of Pennsylvania, an intermediate court, ruled the Pennsylvania State Retirement System (SERS) failed to satisfy its burden to prove "a substantial and demonstrable risk" arising from a request for 15 years' worth of records containing the  "names and addresses of all retirees" from the state.  Therefore, the names and contact information of more than 1,000 retirees, or if deceased, the information on their beneficiaries, must be disclosed by SERS.  And if SERS "failed" in carrying the burden of proving why this should not happen, as the opinion demonstrates, it was not for lack of trying.

The Court recognized an exception from disclosure for retired judges and law enforcement officers on the grounds of specific "personal safety and security" language tied to those positions, contained in Pennsylvania's Right-to-Know Law.

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January 19, 2015 in Cognitive Impairment, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Retirement, State Cases, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)

Friday, January 9, 2015

New study says that first-time criminal behavior by elderly may be early sign of dementia

Via Reuters:

Criminal behavior in older adults, including theft, traffic violations, sexual advances, trespassing, and public urination, may be a sign of dementia, researchers say.  There is a subgroup of people, especially older adults who are first-time offenders, who may have a degenerative brain disease underlying their criminal behavior, said Dr. Georges Naasan of the Memory and Aging Center and Department of Neurology at the University of California, San Francisco.  He and his coauthors reviewed the medical records of 2,397 patients diagnosed with Alzheimer’s disease or other types of dementia between 1999 and 2012. They scanned patient notes for entries about criminal behavior using keywords like ‘arrest,’ ‘DUI,’ ‘shoplift’ and ‘violence’ and uncovered 204 patients, or 8.5 percent, who qualified.  Their behaviors were more often an early sign of frontotemporal dementia (bvFTD) or primary progressive aphasia (PPA), a type of language-deteriorating dementia, than of Alzheimer’s disease.

Read more at Reuters.

January 9, 2015 in Cognitive Impairment, Crimes, Dementia/Alzheimer’s | Permalink | TrackBack (0)

Thursday, January 8, 2015

The "Brink of Understanding" of Alzheimer's Disease

The Denver Post ran an article on Sunday January 4, 2015 about early detection of Alzheimer's. Alzheimer's disease researchers pursue early detection reports about the work researchers have done that has led the, according to one scientist to "the brink of understanding." Researchers at the U. of Colorado in Boulder have been working diligently, with a new drug trial and a proposal for "a federally funded research center..." The article quotes an expert from the Alzheimer's Association about how early detection is so important:

"There's broad recognition now that the brain changes that lead to Alzheimer's disease occur long before there are any symptoms," [Dr. Keith] Fargo said. "By the time changes in cognitive abilities are evident, you have lost a lot of brain cells, and much of what is going to happen with Alzheimer's disease has already happened."

Dr. Fargo goes on to note that it may take 10-20 years before it's actually found and by then, it's too late to undo the damage. Thus the race to find a way to diagnose Alzheimer's before the symptoms  show up.  The article discusses the work researchers are doing to figure out ways to detect the disease early on. These range from using PET scans to blood tests to "genetic profiling." The trial starting at U. of Colorado involves the "protein released in the brain of people with rheumatoid arthritis. They don't develop the disease." Another interesting area of research involves the sense of smell:  those individuals who aren't good at "identifying smells are at high risk of Alzheimer's... [since the] cranial nerve that affects the olfactory sense is one of the first areas involved in brain degeneration."

This is one race we want the researchers to win-soon.

January 8, 2015 in Cognitive Impairment, Dementia/Alzheimer’s, Science | Permalink | Comments (0) | TrackBack (0)

Monday, January 5, 2015

Health Care Decisions for the "Unbefriended" -- a Report from "Aging and Law" Program at 2015 AALS in D.C.

My thanks to Becky Morgan for her words of support regarding the task ahead of me as the incoming chair of the Aging and the Law Section of the American Associations of Law Schools (AALS).  AND, more importantly, our thanks to Mark Bauer, from Stetson Law, the outgoing chair on Aging, and Thaddeus Pope, Hamline Law, the chair of the Law, Medicine and Healthcare Section, who worked together to present a great program.

The focus of the 2015 joint program was examination of how health care providers approach the question of medical decisions -- and not just end-of-life treatment decisions -- for a unique, but not rare, group of individuals.  We were asked to consider whether current law and practice adequately serve those who have not expressed their views in advance (such as by a written "living will" or other care directive), have not appointed a surrogate decision maker (such as by naming an agent in a written directive, whether in the form of a Power of Attorney or specialized health-care directive),  are not able personally to communicate with a doctor or care provider to give direction and consent to treatment, and for whom there is no family member or close individual recognized by formal law or informal practice as having decision-making authority.  Sometime this individual is simply someone who has outlived her family and close friends.

The discussion was good, especially with the help of the 50-state legal review from the wonderful Erica Wood of the American Bar Association's Commission on Law and Aging, and key practical perspectives and experiences from Ellen Fox, M.D., who was Chief Officer, Ethics in Health Care, for the Department of Veterans Affairs for 15 years, and who now is the CEO for Integrated Ethics Consulting LLC.  

David Orentlicher. J.D., M.D., and the co-director of the Center for Law and Health at Indiana University School of Law provided an intriguing examination of "clear and convincing evidence" standards as used in health-care decision making for "unbefriended" patients.  Sharona Hoffman, from Case Western Reserve Law also added good food for thought, including talking about "precedent autonomy," which for me was a new label to consider.  This latter concept resonated with me on a personal level, as for many years my father made it very clear how he did not want to live under certain circumstances if he developed certain disabling conditions, but who now seems to have quite a different view -- acceptance of life, perhaps --"with" dementia.   

Great discussion, including wise observations from members of the audience about the number of years that society has struggled with these issues of treatment decisions for those who cannot express their personal wishes, and the incremental (and sometimes frustrating) nature of change.

I always hope to come away from AALS programs with new things to read and study, both for myself and my students.  So, along that line, here are two takeaways:

 

January 5, 2015 in Cognitive Impairment, Ethical Issues, Health Care/Long Term Care | Permalink | Comments (0) | TrackBack (0)

Wednesday, December 31, 2014

Doctors Discussing Driving with Patients

One of the more lively class discussions in my seminar occurs when we take up the issue of older drivers.  All of my students have had some experience with an older driver, and it provides me the opportunity to cover the laws regarding driving as well as the implications of loss of driving privileges.

The Cleveland Clinic Journal of Medicine recently ran a column on when doctors should discuss driving issues with their elder patients .When should I discuss driving with my older patients? discusses different medical conditions and possible implications on safe driving. The article also covers the importance of being able to drive (at least to those of us in the U.S.) and the impact on an individual when the ability to drive is lost.  The article explains the value of using driver evaluations:

It is therefore understandable for health care providers to feel reluctant or uncomfortable counseling older adults to give up their driving privileges. A health care provider who identifies driving safety concerns can refer a patient to a geriatrician        for further risk assessment or to a certified driver rehabilitation specialist (CDRS) for a driving evaluation. A CDRS will also offer the patient and caregiver information on local resources for transportation alternatives. A list of local CDRSs can be found on the Association for Driver Rehabilitation Specialists website (www.aded.net). Many hospitals have occupational therapists who are CDRSs.

The article mentions that the evaluation includes not only an assessment of the "rules of the road" but also a cognitive evaluation as well as a driving test if the evaluator deems one necessary.  There is a possibility that Medicare may provide payment; that "depends on diagnosis and the state carrier."

December 31, 2014 in Cognitive Impairment | Permalink | Comments (2) | TrackBack (0)

Tuesday, December 30, 2014

Individualized Activities Helpful for Individuals with Dementia: Research Study

Researchers at the Polisher Institute at the Abramson Center for Jewish Life have published the results of a controlled study on use of non-drug approaches to behavioral assistance for individuals with dementia. 

The study, titled "A Randomized Controlled Trial for an Individualized Positive Psychosocial Intervention for the Affective and Behavioral Symptoms of Dementia in Nursing Home Residents," is published in the January issue of the Journal of Gerontology (Series B: Psychological Sciences), which is accessible via subscription.  From the abstract:

Objectives. This randomized controlled study tested the effectiveness of individualized activities, led by certified nursing assistants (CNAs), to increase positive and reduce negative affect and behavior among nursing home residents with dementia.

 

Method. Nursing home residents with mild to advanced dementia (N = 180) were randomly assigned to usual care (UC, n = 93) or 1 of 2 experimental conditions. Residents in the attention control group (AC, N = 43) participated in standardized one-to-one activities with their CNAs. Individualized Positive Psychosocial Intervention (IPPI) participants (n = 44) received a CNA-led activity matched to their interests and ability. Outcomes were residents’ positive and negative affect and verbal and nonverbal behavior.

 

Results. The IPPI and AC groups experienced similar benefits—more pleasure, alertness, engagement, positive touch, and positive verbal behavior—compared with UC. The AC group displayed more anger, uncooperativeness, and very negative verbal behavior than UC or IPPI.

                 

Discussion. This study demonstrates the value of individualized activities for nursing home residents with dementia. In a stringent test, residents were happier and less angry during a customized intervention compared with a standardized intervention. Even brief individualized CNA-led activities bring pleasure to nursing home residents and constitute an effective strategy to enhance positive affect and engagement in persons with dementia.

It would be interesting to know more about what appears to be a potentially significant difference not only between the "standardized" interventions and the "individualized" approaches, but also between the different types of individualized approaches.                   

December 30, 2014 in Cognitive Impairment, Dementia/Alzheimer’s, Health Care/Long Term Care, Science | Permalink | Comments (0) | TrackBack (0)

Tuesday, December 23, 2014

More Good Reasons to Exercise Regularly (Hint: It Helps Your Brain)

A timely reminder during this holiday season, and as we plan our New Year's Resolutions.  Exercise regularly!  From the Washington Post, reports of research from the University of Wisconsin School of Medicine and Public Health: 

Evidence continues to accumulate that physical activity can help hold off the changes in the brain associated with Alzheimer's Disease, and perhaps the devastating symptoms  of the disease itself. The latest information comes from researchers at the University of Wisconsin School of Medicine and Public Health, who looked at 317 late-middle aged adults and determined that those who exercised five times a week or more had fewer of the age-related changes in the brain that are associated with the disease, and did better on cognitive tests.

 

Age remains the single greatest risk factor for Alzheimer's, greater even than having the gene found in many people with the disease, the study confirmed. But "what we have shown here is that physical activity diminishes the deleterious influence of age," said  Ozioma Okonkwo, an assistant professor of medicine at the school who led the study.

December 23, 2014 in Cognitive Impairment, Dementia/Alzheimer’s | Permalink | Comments (0) | TrackBack (0)

Friday, December 19, 2014

Is Your Job Good for Your Brain?

The journal Neurology, ran an article about a recent study on the impact occupations have on workers' brains.  Occupational complexity and lifetime cognitive abilities opens with a recognition that "[t]here is a growing body of research suggesting that more stimulating lifestyles, including more complex work environments, are associated with better cognitive outcomes in later life." (citations omitted).

In the discussion, the authors note that "[t]he ... findings support the hypothesis that higher complexity of work is associated with later-life cognitive performance...."  After discussing the specifics of the study, the authors offer this summary "the current study  supports an association between more complex lifetime occupations and better cognitive abilities in later life. Of note, the evidence in favor of the differential preservation of cognitive abilities has been examined in the context of accounting for the likelihood of persevered differentiation, a major issue in the search for determinants of cognitive aging."

The full text of the article is available here.

December 19, 2014 in Cognitive Impairment | Permalink | Comments (0) | TrackBack (0)

Wednesday, December 17, 2014

Stanford Releases New Study on Factors That May Affect Development of Alzhemier's

Researchers at Stanford Unviersity School of Medicine have released their latest study of brain cell degeneration in mice, suggesting the potential importance of blocking the influence of certain molecular processes associated with inflamation and Alzheimer's disease:

“'Microglia are the brain’s beat cops,' said Katrin Andreasson, MD, professor of neurology and neurological sciences and the study’s senior author. 'Our experiments show that keeping them on the right track counters memory loss and preserves healthy brain physiology.'”

Here is Stanford's new release, summarizing the study published this month in the Journal of Clinical Investigation.  Hat tip to Dickinson Law's Professor Laurel Terry for sharing this news.

December 17, 2014 in Cognitive Impairment, Dementia/Alzheimer’s, Science | Permalink | Comments (0) | TrackBack (0)

Tuesday, December 16, 2014

Did You Catch NPR's "Old and Overmedicated?" (Links and Updates Here)

Mark Friedman, an elder law and special needs attorney from New Jersey, recently wrote to comment on the important series offered by National Public Radio on use and misuse of certain medications in long-term care settings.  Here is what Mark said:

"NPR ran a story on 'chemical restraints,' - nursing homes using anti-psychotic drugs to make unruly residents more pliable. According to the article, the residents are usually Alzheimer’s or dementia patients, and anti-psychotics can make the residents easier for staff to manage. But the drugs can be dangerous, increasing a resident’s risk of falls and exacerbating health problems. At high doses, anti-psychotics can also sap away emotions and personality and put the resident into a 'stupor.'

 

Administering drugs in this manner, any drugs, including anti-psychotics, without medical need and for the convenience of staff, is contrary to federal regulations. Unfortunately, it may also be widespread.

 

The NPR story includes a tool drawn from CMS data that shows the rate of residents on anti-psychotics at nursing homes across the country. You can look up the facility in which your loved one resides.

 

The news coverage shows that this issue is getting increased attention, and that’s a good thing. I think that as Americans age and more people have spouses and parents in nursing homes, the use of anti-psychotics as chemical restraints will have to diminish or end. People won’t stand for their loved ones being drugged into a stupor."

Thanks, Mark, for making sure we included this topic and the latest links for more coverage and your additional commentary.  Along the same lines, I listened to an interesting follow-up conversation on AirTalk, a Los Angeles public radio affiliate's program, discussing "How California is Doing in the National Fight to Curb Over-Medication of Nursing Home Patients."  That program, now available as a 23-minute podcast, included an articulate medical professional, Dr. Karl Steinberg, who described how he sees medication practices changing in long-term care, including better use of behavior health techniques, rather than medication, to help residents.

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December 16, 2014 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Science | Permalink | Comments (0) | TrackBack (0)

Saturday, December 13, 2014

Los Angeles Public Radio Affilliate Continues Discussion on Capacity and Consent

AirTalk, a program aired daily by Public Radio affilliate KPCC in Southern California, hosted a discussion about the issues identified in news articles about the Iowa criminal case, where a husband faces "statutory rape" charges for having sexual relations with his wife after she was diagnosed with advanced dementia and began residing in a nursing home.

Here's the link to a podcast of the December 12, 2014 segment.

December 13, 2014 in Cognitive Impairment, Crimes, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)

Thursday, December 11, 2014

When Does Dementia Mean You No Longer Have the Right to Say Yes to Sexual Activity?

In August, I reported on criminal charges filed that month in Iowa, charging a husband with sexual abuse of his wife who was living in a nursing home. 

As a result of that post, I was invited by a reporter, who was working on an extended analysis of the case, to review certain information and records emerging from the case. Much of my own research is closely focused on issues both of capacity and protection.

The more one reads about the Iowa case, the sadder it seems.  Even though at first it seemed the husband, a state legislator, might be expected to have sophisticated legal knowledge of the implications of what it might mean for his wife to be diagnosed with dementia, it became pretty clear -- at least to me, reading from afar -- that the husband is a fairly simple guy: A farmer, high school education, part-time legislator who liked pig roasts and parades, and someone who cared deeply for his second wife, trying as hard as possible to see her as "just a little" impaired. 

I suspect that for many of us who have experiences with a loved one with dementia, there is a phase of denial, not just about the fact of dementia, but about the level of dementia. I remember one instance where a client always had her husband sign their joint tax returns, because even with Alzheimer's, he was "able" to sign his name clearly.   

Reading the statute used to charge the Iowa husband also gave me pause. Iowa Code Section 709 was the basis of the sexual abuse charges.  Sexual abuse in the third degree under Section 709.4 could be charged where a sex act "is done by force or against the will of the other person." That provision did not seem to apply.  Charges could also be brought where the act is between persons who are not cohabiting as husband and wife, "if any of the following" is true: "The other person is suffering from a mental defect or incapacity which precludes giving consent."

Section 709.1A of the Act defines "incapacitation" to include "mentally incapacitated" or "physically incapacitated" and neither quite seemed to apply.  Under Iowa law, "mentally incapacitated" means that a person is "temporarily incapable of apprising or controlling the person's own conduct due to the influence of a narcotic, anesthetic, or intoxicating substance."  And "physically incapacitated" means that a person has a bodily impairment or handicap that substantially limits the person's ability to resist or flee."

So, how was the husband charged?  He was charged under Section 709.4 (2)(a) on the grounds that his wife, with whom he was not "cohabiting," suffered from a "mental defect" that precluded giving consent.

So that makes the "elder  law" issue fairly stark: Has his wife's diagnosis of dementia, especially advanced dementia, prevented her from giving legally effective "consent?"

Continue reading

December 11, 2014 in Cognitive Impairment, Crimes, Dementia/Alzheimer’s, State Cases, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)

Thursday, December 4, 2014

Canada: Alzheimer's health club offering new type of care for seniors

Via the Toronto Star:

Ever since she was a teenager, Ashley Kwong knew she wanted to open her own seniors’ home. Now, almost two decades later, her dream is finally becoming a reality.  Kwong is launching Memory & Company next spring — and she’s touting the Markham facility as Canada’s first private Alzheimer’s program.  Kwong says Memory & Company will have a spalike feel, with well-lit rooms, secured outdoor spaces and programming such as music therapy, gardening and yoga. There will be a five-to-one staffing ratio and an on-site nurse.  Costs, which range from $100 per day for basic care to $150 for those with more advanced Alzheimer’s, are on a par with many long-term care facilities and retirement homes. While more expensive than many day programs, Memory & Company will offer a different type of experience, catered specifically to the needs of people with Alzheimer’s and dementia, Kwong says.  Clients will be free to roam the health club’s 11,000-square-foot space with a circular design to decrease their dementia-related agitation while wandering through the rooms. Clients will also have access to a salon, gym, dance studio and hydrotherapy spa, alongside outside services like massages and physiotherapy.  “We’re also using iPad technology to provide more individualized care, instead of planning the whole program for the month and not caring what people are in the building,” Kwong says. “It’s a different approach than the assembly style of day programs right now.”

Read more at the Toronto Star.

December 4, 2014 in Cognitive Impairment, Dementia/Alzheimer’s, Health Care/Long Term Care, International | Permalink | TrackBack (0)

Monday, December 1, 2014

Oregon Bar Bulletin Addresses Cognitive Decline Issues for Lawyers

In the November 2014 issue of the Oregon State Bar Bulletin, an attorney-counselor at the Oregon Attorney Assistance Program, Douglas Querin, reports that he has had more calls over the past two to three years involving questions of age-related cognitive decline than in all the previous years he has worked in his position. 

One factor potentially contributing to an increase is the number of lawyers who may be staying in practice longer, as a result of the economic downturn's effect on their retirement savings.  In Oregon, more than a quarter of all lawyers are age 60 or over, and nearly half of the active members in the Oregon bar are age 50 or over.

"'The most heartbreaking situations are where a lawyer may have had a stellar reputation for 30 to 50 years of practicing, then changes with cognitive issues, in part because no one raises the problem, and he keeps practicing and gets into trouble, which raises the attention of the bar,' [Assistance Program Attorney Querin] says.  'Then you have a senior lawyer with a great reputation whose legacy ends up being under an ethical cloud.'

 

By the time such discussions take place, the impaired lawyer's reaction may be denial, because part of the cognitive changes may include the inability to recognize that a problem exists, says [Oregon neuropsychologist Michael R. Villaneuva]. 'An inability to know there are difficulties is part of the nature of what's happening to them.'"

In "Ready or Not: When Colleagues Experience Cognitive Decline,"  author Cliff Collins details signs and symptoms of potential cognitive impairment, drawing upon the ABA Senior Lawyer Assistance Committee's 2014 Working Paper on Cognitive Impairment and Cognitive Decline Worksheet. The article further suggests approaches to take with colleagues and urges members of the profession not to "ignore" any problems. 

A companion article in the issue further addresses "Ethical Implications of Aging - The Graying of the Profession," including specific guidance in the ABA Model Rules of Professional Conduct and relevant formal ethics opinions. 

"Thank you" to Dickinson Law Professor Laurel Terry for sharing her copy of the Oregon State Bar Bulletin.

December 1, 2014 in Cognitive Impairment, Ethical Issues, Legal Practice/Practice Management | Permalink | Comments (0) | TrackBack (0)

Overcoming Distractions--Training the Aging Brain?

There are so many things vying for our attention, and many of us may find ourselves easily distracted (say for example, by shiny objects). I like to use the example of Dug the talking dog from the fabulous movie, Up. (Going off on a tangent, consider using this movie in your classes, it's great) But I digress...or perhaps I was distracted....

Kurzweil AI ran an article on November 26th, 2014 reporting on a study on how to train an "aging brain" to ignore distractions. Disruptive sounds help aging brain ignore distractions reports on a new study, the results of which are published in the journal, Neuron. The study, Adaptive Training Diminishes Distractibility in Aging across Species is available with subscription or by purchase here.  The abstract explains the study:

Aging is associated with deficits in the ability to ignore distractions, which has not yet been remediated by any neurotherapeutic approach. Here, in parallel auditory experiments with older rats and humans, we evaluated a targeted cognitive training approach that adaptively manipulated distractor challenge. Training resulted in enhanced discrimination abilities in the setting of irrelevant information in both species that was driven by selectively diminished distraction-related errors. Neural responses to distractors in auditory cortex were selectively reduced in both species, mimicking the behavioral effects. Sensory receptive fields in trained rats exhibited improved spectral and spatial selectivity. Frontal theta measures of top-down engagement with distractors were selectively restrained in trained humans. Finally, training gains generalized to group and individual level benefits in aspects of working memory and sustained attention. Thus, we demonstrate converging cross-species evidence for training-induced selective plasticity of distractor processing at multiple neural scales, benefitting distractor suppression and cognitive control.

Back to the Kurzweil AI article about the study. The Kurzweil story notes that "[d]istractibility (the inability to sustain focus on a goal due to attention to irrelevant stimuli) can have a negative effect on basic daily activities, and is a hallmark of the aging mind." The article notes the applicability of the research, including applications for individuals with autism or for "individuals struggling with a variety of distractions." The Kurzweil article  notes the two-fold results of the study, "highlighting the therapeutic potential of this type of brain training to improve our ability to focus with age, it also shows that even in the aged adult, the brain is responsive to learning-based approaches that can improve cognition."

I was  pondering the results of this study vis a vis individuals suspected of having diminished capacity.  I was wondering whether there is application of the training to those individuals who may have difficulty with some ADLS if due to distractability. Would this be a temporary or long term solution and an alternative to guardianship for some? 

December 1, 2014 in Cognitive Impairment, Dementia/Alzheimer’s | Permalink | Comments (0) | TrackBack (0)

Thursday, November 27, 2014

The "Aging" Art of Communication - A Holiday Topic?

Recently I have encountered several thoughtful articles about the language we use, and the approaches taken, when talking with older persons.  This seems to be an especially appropriate topic for the holiday season, when families often come together, sometimes from great distances. Whether we are talking with clients or family members, some of the same dynamics may be in play, especially when the question is about planning for the future.

From the ABA Commission on Law and Aging's Bifocal publication, comes David Solie's "The Wrong Signals: Shutting Down the Planning Conversation Before It Starts."  He encourages us to "consider the psychological landscape of older clients -- it is a world embedded with two dominant agendas posing significant resistance to change. Together, these psychological currents create a deep inertia to disrupting the status quo."  He labels these barriers to change as:

  • Ambivalence and the "Righting Reflex," and
  • The Need for Control

He suggests approaches, including the use of open-ended questions, reflective listening, and making a conscious decision about what words to use.  For example, he suggests that when we start to discussion options, we explain more clearly that advance planning helps to "preserve choice" and avoids "loss of control."   

Another potential problem may arise from "Elderspeak," a label social scientists use to refer to a tendency to use "patronizing" tones or words when speaking to anyone who is older.  One recent article in McKnight's News made me chuckle, as it points to the well-meaning but potentially misguided use of words such as ""honey" by professionals when working with elders. 

My father, a federal judge for more than 30 years, at age 89 may have forgotten many things -- but he does not take kindly to being called "honey" by strangers.  He now has an entire assisted living campus, even a few of the other residents, calling him "Judge" or "Your Honor." I bet you might know a judge or two like that?  When it comes to control, I'm not sure who is teaching whom about  holding court.  

Here's to more humor in all of our holidays -- and more opportunities for effective communication -- both within the family and beyond.  Happy Thanksgiving!

November 27, 2014 in Cognitive Impairment, Ethical Issues, Housing, Retirement, Science | Permalink | Comments (0) | TrackBack (0)

Tuesday, November 25, 2014

Thank a Caregiver

Ramping up into Thanksgiving celebration, thinking about the things for which we are thankful---how about adding caregivers to that list? Huffintong Post Third Metric ran a three-part series earlier this month on Unsung Heroes: The Face of American Caregiving. The Unsung Heroes Who Give Up Everything To Take Care Of A Sick Partner, the first installment in the series, focused on eleven extraordinary caregivers providing care to spouses/partners.  The second,  The Unsung Heroes Who Give Up Everything To Take Care Of A Sick Parent covers 10 family members providing care for their parents., 9 of whom are over the age of 50.  The final installment, The Unsung Heroes Who Give Up Everything To Take Care Of Multiple Loved Ones covers ten amazing individuals who have provided care for multiple generations.

Knowing the statistics on caregiving, a number of us will be called upon to provide the care. These folks will inspire you.  Happy Thanksgiving.

November 25, 2014 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Retirement | Permalink | Comments (0) | TrackBack (0)