Tuesday, February 13, 2018

A Seldom Discussed Legal Issue? The Problem of Smokers with Dementia

My family has been struggling with the issue of what to do about the increasing safety risk of a family member who, at age 90+, is still a smoker, but now also a smoker with dementia. Our family has long since given up on the direct health risk of smoking for the individual.  But the evidence of a greater risk is everywhere:  small burn holes in the carpets, on the arms of a favorite chair, and even melted spots on the linoleum on the kitchen floor beneath the smoker's chair.  The latest sign of a serious problem frightened us the most -- a burned hole in the sheets of the bed.  Before dementia this individual never smoked in bed; but with dementia, plus problems walking and sitting in a chair, she began to insist on her "first" morning cigarette while still in bed.  The situation requires constant monitoring -- but even that is a challenge as it can be hard to find companions who can tolerate this level of smoking.  

There is plenty of evidence the risk is more than just to the smoker's health.  See, for example, the news link below for a report on a fire that caused the death of the elderly smoker and injuries to the firefighters. 

For discussions of approaches to managing, if not stopping the elder's smoking, see also Caring.com on "Should I Take Cigarettes Away From My Mother, Who has Alzheimer's?  One person commenting on the column, describes the situation with his own mother as a "dreadful problem. . . . It is the most difficult situation I have ever faced with her and there is no easy solution." Another person provided the following history:

The problem has miraculously resolved itself with the help of some very skilled caregivers. I had to move my [92 year old] mother to a Memory Unit in an Assisted Living Facility. They agreed that she could have 4 cigarettes per day under their supervision. They made an exception for her. For the first several months she asked repeatedly all day long for a cigarette. They patiently distracted her by redirecting her attention or promising a cigarette after dinner, whatever. It didn't stop her begging for a smoke over and over but now, at age 94 and with advancing dementia, she has almost forgotten that she's a smoker. 

That's an important caveat -- with dementia, at 94 -- she has "almost forgotten that she's a smoker." 

February 13, 2018 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Health Care/Long Term Care | Permalink | Comments (0)

Monday, February 12, 2018

Kaiser Health Offers Q & A on "Living Well with Dementia" on Tuesday, Feb 13

Sorry for the late news but Kaiser Health News is offering a live discussion via Facebook Live! and Twitter on "Living Well with Dementia" on Tuesday, February 13, from 12:30 to 2:00 p.m. Eastern Time.

Hear are details:  

Join Kaiser Health News on Tuesday, Feb. 13, from 12:30 to 2:00 p.m. ET for an informative and important discussion about improving care and services for people with dementia and supporting their caregivers. It’s an opportunity to learn from experts in the field about the challenges and difficulties facing the patient, the caregiver, the community and policymakers. Topics will include understanding the stages of dementia from a medical, social, psychological and environmental perspective (it’s not just memory loss); how to find help; how to manage difficult behaviors; and understanding medications for people with dementia. 

Kaiser Health News’ “Navigating Aging” columnist Judith Graham will moderate a discussion with you and a panel of experts as we explore this issue.

Our panelists are:

  • Nancy A. Hodgson, Ph.D., RN, FAAN, University of Pennsylvania, an expert on dementia care and end-of-life care for people with dementia; 
  • Helen Kales, M.D., University of Michigan, a geriatric psychiatrist and expert on dementia care and mental health issues; 
  • Yvonne Latty, BFA, MA, a journalist and professor, who is dealing with her mother’s Alzheimer’s;
  • Katie Maslow, MSW, Gerontological Society of America, an expert on improving care for people with dementia and supporting their caregivers; and
  • Mary L. Radnofsky, Ph.D., a former professor who lives independently since being diagnosed twelve years ago with dementia and is an advocate for people with dementia.

February 12, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Science | Permalink | Comments (0)

Friday, January 26, 2018

New Mexico Legislature Considers Comprehensive Reform of Guardianship Laws, Following Fraud & Embezzlement Scandals

In a bipartisan effort, two New Mexico state senators have introduced Senate Bill 19 -- some 187 pages in length -- in an effort to completely overhaul the state's laws governing guardianships in New Mexico.  The proposed changes, which largely track the Uniform Law Commission's recommendations for "Guardianship, Conservatorship and Other Protective Arrangements," will make such proceedings open to the public and require more notification of family members about the process.  The reform follows high-profile scandals involving two companies that are alleged to have "embezzled millions of dollars of client funds," while appointed-guardians also sometimes restricted family access to their wards.

Hearings on the bill began on January 25, 2018, during the regular 30-day session of the legislature.  From the Albuquerque Journal's coverage on the reforms:

Under the bill pending at the Roundhouse, legal guardians would not be able to bar visitors – both in person and via letters and emails – unless they could show the visit would pose significant risk to the individual or if authorized to do so by a court order.

 

[State Senator and Co-Sponsor of SB 19 Jim White] said the legislation does not call for any additional funding to be appropriated, though it could shift some money from the state guardianship commission to the courts for administrative duties. His bill is the only bill filed so far on the issue of guardianships, though others could be introduced in the coming weeks.

 

Meanwhile, the proposed law would also permit bonds to be required of conservators – a protection already proposed by the New Mexico guardianship commission and recently put into place by district judges in Albuquerque.

For more on the criminal charges filed against executives at Ayudando Gaurdians Inc. and Desert State Life Management, read Who Guards the Guardians? by Colleen Heild. 

January 26, 2018 in Cognitive Impairment, Consumer Information, Crimes, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Thursday, January 25, 2018

What Does An Alzheimer's Patient Look Like? She Looks LIke All of Us

Kaiser Health News ran a very interesting story, Postcard From California: Alzheimer’s ‘Looks Like Me, It Looks Like You’. The article opens with the story of an attorney who has early onset Alzheimer's who recounts her experiences as part of a panel discussion.  "Sponsored by Northern California and Northern Nevada Chapter of the Alzheimer’s Association, the event was part of an initiative to highlight the disease’s impact on women, who account for two-thirds of people living with Alzheimer’s and two-thirds of those caring for them... About 630,000 people have Alzheimer’s disease in California, and women in their 60s have a 1 in 6 chance of developing the disease — almost twice as high as the risk of developing breast cancer."  One of the most compelling quotes in this story came from a panelist who said this "'“Alzheimer’s looks like me, it looks like you, it looks like everyone,'" [she] ...  said." The story closes with advice from one of the panelists about the importance of doing what makes one happy.  Good advice.

January 25, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Programs/CLEs | Permalink | Comments (0)

Netherlands: Examining Physician's Actions in Euthanasia Death of 74-Year Old Woman with Dementia

As my blogging colleague Becky Morgan has highlighted in two of her posts this week, about a February conference at Hastings and recent proposals for "dementia advance directives," end-of-life decisions are increasingly high-profile topics for those working in law, medicine and ethics.  Add to this the case under review in the Netherlands, where a physician described as a "nursing home doctor" performed euthanasia for a 74-year old woman with "severe dementia." A Dutch law legalizing euthanasia, that came into effect in 2002 and that was recently the subject of new "guidelines for performing euthanasia on people with severe dementia," is also under review.  From Dutch News in September 2017:

The case centres on a 74-year-old woman, who was diagnosed with dementia five years ago. At the time she completed a living will, saying she did not want to go into a home and that she wished to die when she considered the time was right. After her condition deteriorated, she was placed in a nursing home where she became fearful and angry and took to wandering through the corridors at night.The nursing home doctor reviewed her case and decided that the woman was suffering unbearably, which would justify her wish to die.

 

The doctor put a drug designed to make her sleep into her coffee which is against the rules. She also pressed ahead with inserting a drip into the woman’s arm despite her protests and asked her family to hold her down, according to the official report on the death. This too contravenes the guidelines. Once the public prosecution department has finished its investigation it will decide whether or not the doctor, a specialist in geriatric medicine, should face criminal charges.

In reading articles about this matter, I'm struck by how often the articles (and my own post here) draw attention to the woman's age, comparatively "young" at 74, as well as the fact that her euthanasia directive written five years earlier also expressed her wish not to leave her home.  If an individual is younger -- with dementia -- does that reduce society's willingness to "allow" aid in dying? If individuals are older -- and what age is old enough -- is it less controversial? And is a family bound by the individual's wishes not to leave her home?  Tough questions, indeed.

This case has also drawn attention in commentary in the US, including a January 24, 2018  Washington Post piece with the provocative title, How Many Botched Cases Would It Take to End Euthanasia of the Vulnerable?   

January 25, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, International | Permalink | Comments (0)

Monday, January 22, 2018

The Importance of Friendship in Later Life & Caregiving

As I type this, it is 5 in the morning and I'm thinking about my "to do" list for the day.  I've already baked cinnamon rolls, the kind my mom likes best.  My list includes talking to my mother's accountant about a problem with W-2 tax forms for 2 of the 4 caregivers who help mom in her home. It includes setting an appointment wih the latest addition to the team, a physical therapist.  I also need to get the forms from my mom's long-term care insurance company, to start the paperwork for an assessment.  And, that leads into another item on my list, stopping at two residential living communities to drop off  "deposits" to hold spots, while my sister and I work towards the possibility -- no, the probability -- of that difficult decision.

As I think about these small tasks, all of which I need to complete before I head to the airport for another red-eye flight between Arizona and Pennsylvania, I'm also thinking about how important friendships are in later life.  Not just my mother's friends, but my own.  Over the weekend, I spent lots of time talking with a long-time friend. We grew up together and used to ride horses.  As I type this blog post, I can see a funny, faded, framed photo on the wall of my childhood bedroom showing the two of us, plus two more friends, competing as a team in a "4s" class, a riding event that probably no longer even exists. We look so serious as we tried to keep our three chestnut horses plus one palomino in step (and from kicking each other). Riding 4s (2)  
Our elder care interests and careers now overlap as she operates a small personal care home, licensed to provide assisted living. We sometimes joke that we started learning about caregiving in 4-H, although back then our charges  were more likely to be critters. How I wish my friend's care center was an option for my mother, but unfortunately it is too far from my sister's home and job to be practical.

Instead, we talked strategies and other options. She had great advice about switching my mother over to electronic cigarettes, to make a transition to a "no smoking home" a bit easier.  Her mother, who's close to my mother's age, is also struggling with staying in her own home.  Ironic, isn't it, that my friend runs one of the best care homes in the city, but her mother won't even visit?  Sort of like the elder law professor whose parents resisted making plans?

But, as my friend said this weekend, caregiving decisions somehow "seem" different when you are talking about your own parent. The same is true for elder law advice. Even as she and I were giving each other "great" advice, we knew it was hard to follow that advice for our own mothers as they resist major changes.   

It was great to have her to talk with this weekend. My friend understood.  

That wasn't the only important friendship over the weekend.  One of my sister's long time friends interrupted a grocery shopping expedition and joined us on a car ride with our mother.  Her lively, funny conversation kept the tone light and upbeat, even as we did our first drive-by with mom, to look at the outside -- just the outside -- of one care center option that is nearby.  That friend, too, is caring for her mother and sometimes it is our turn to join them to create an "evening out "  

Another friend this weekend is the gal who I came to know so well as the director of the wonderful place where my father lived for many months.  She interrupted her "off duty" weekend to talk to me as a friend about choices.

A cherished neighbor and friend of my mother's also texted me early today, to ask about mom's weekend, even as she is juggling duties to help her husband in a rehab facility, where he is recovering from a broken hip.

I heard from a friend in Florida who lives in a terrific CCRC and she always offers a great ear and sage advice (along with lots of good leads for this Blog).

Another friend actually offered to fly out to Arizona to help -- and she lives in the Virgin Islands.  She, too, is helping an aging parent in the states.

I know that when I return to my classrooms in Pennsylvania later this week, individual students will ask, "how did it go?" And they will undoubtedly surprise me with their patience with our interrupted syllabus and make-up classes.  

Friends who understand.  

I could keep typing for a long time to describe our many friends and the important roles we play in each other's lives.  I know -- and hope -- that many of our readers are supported in their caregiving journeys by such wonderful "late-in-life" friendships. Thank you all,

 

January 22, 2018 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Housing | Permalink | Comments (1)

Increasing Awareness and Understanding of Frontotemporal Dementia

A good friend and Penn State colleague, Dr. Claire Flaherty, a neuropsychologist at Penn State Hershey Medical Center, was part of a recent program explaining frontotemporal dementia, a condition which is often subtle, but nonetheless potentially devastating, especially when misdiagnosed.  Here's the link to the podcast of the program, from a local television station in Pennsylvania. 

 

 

January 22, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Science | Permalink | Comments (0)

Sunday, January 21, 2018

Dementia Advance Directive?

I read a recent article in the New York Times as part of the New Old Age Series. Paula Span writes  One Day Your Mind May Fade. At Least You’ll Have a Plan. The article is about advance directives for those with dementia as discussed in a recent article published in the Journal of the American Medical Association (JAMA).  The idea of the dementia-specific advance directive is to express your wishes based on the specific "phase" of dementia you may enter in the future.  The website for this directive is here from which the 5-page directive may be downloaded.  The NY Times article describes the directive "In simple language, it maps out the effects of mild, moderate and severe dementia, and asks patients to specify which medical interventions they would want — and not want — at each phase of the illness."

In the JAMA article, the authors make the case that other existing advance directives aren't particularly helpful for those with dementia because of the way it progresses over time with corresponding diminishing cognitive function (a subscription is required to access the article).  The NY Times article notes that "[a]lthough [dementia] is a terminal disease, dementia often intensifies slowly, over many years. The point at which dementia patients can no longer direct their own care isn’t predictable or obvious. ... Moreover, patients’ goals and preferences might well change over time. In the early stage, life may remain enjoyable and rewarding despite memory problems or difficulties with daily tasks."

The dementia-specific directive describes the person's wishes  as "goals of care" and offers four options for each stage of dementia, directing the person to "[s]elect one of the 4 main goals of care listed below to express your wishes. Choose the goal of care that describes what you would want at this stage."  The directive divides dementia into three stages, mild, moderate and severe.

There are already a number of types of advance directives, with recent pushes for POLST and other initiatives such as the Conversation Project.   Then there is the Five Wishes document,  which as been around for a number of years. Attorneys may be incorporating dementia-specific instructions into advance directives already.

Interesting.

 

January 21, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Friday, January 19, 2018

UPitt Law Prof Larry Frolik Urges Change in Pennsylvania Guardianship Law to Clarify Lawyer's Role in Representing Alleged Incapacitated Persons

Larry Frolik, University of Pittsburgh Law Professor and all-round elder law guru, responds to a 2016 decision by the Pennsylvania Superior Court for In re Sabatino with a strong call for change in existing guardianship laws.  In the abstract for his January 2018 article for the Pennsylvania Bar Association Quarterly on The Role of Counsel for an Alleged Incapacitated Person in Pennsylvania Guardianship Proceedings [currently membership-restricted], he writes:  

When a petition is filed requesting that court find an individual to be incapacitated and appoint a guardian for the individual, the alleged incapacitated person [AIP] has a right to counsel. If the individual does not have counsel, the court may, but is not required to,  appoint counsel. Whether counsel is hired by the [AIP] or appointed by the court, the question arises as to what is the proper role of counsel.  Should counsel act solely as a zealous advocate and attempt to resist the imposition of the guardianship if so directed by the [AIP] or should counsel act in the best interest of the person with counsel making the determination of what is in the person's best interest?

 

A 2016 Superior Court case considered that issue and concluded that if the [AIP] desired not to have a guardian, counsel should so inform the court, but counsel, acting in what counsel believed was the person's best interest, could also tell the court that counsel believed that the person needed a guardian.  That holding is not consistent with the fundamental obligation of counsel to advocate for what the client, the [AIP], desires.  Counsel should not be making an independent determination that the person would be better served if a guardian were to be appointed.  The decisions as to whether an [AIP] is legally incapacitated and, if so, whether the appointment of a guardian is appropriate, are decisions that only a court should make.  

 

The Pennsylvania Legislature should amend the law of guardianship to clarify that the role of counsel for an [AIP] is that of a zealous advocate, and that counsel should not act in what counsel believes are the person's best interest.  If the Legislature does not act, in the future courts should reexamine the issue and rule that counsel should act solely as a zealous advocate and not attempt to promote the person's best interest. 

January 19, 2018 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Legal Practice/Practice Management, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Wednesday, January 17, 2018

What Does it Mean to Have a "Perfect Score" on a Cognitive Assessment Test?

I've sat in on dozens of mental acuity screening exams for individuals exhibiting indications of some form of dementia.  

Regarding the "perfect score" reportedly received by President Donald Trump on a mental acuity screening test during his January health exam, it may be helpful to consider what is -- and isn't -- covered by such assessments.  One view is provided in an opinion piece this week in the Washington Post, using history from a criminal case where Brooke Astor's son and an attorney were found guilty of exploiting her alleged mental incapacity.    From the article: 

On its surface, the Montreal Cognitive Assessment (MoCA) test seems pretty easy. Can you draw a three-dimensional cube? Can you identify these various animals? Can you draw a clock? Can you repeat back the phrase, “The cat always hid under the couch when dogs were in the room”? . . . 

 

If you look at the test, it’s pretty hard to see how you could not score a 30. You see a picture of a lion and have to identify it as a lion? That old joke about how the elderly and toddlers are subject to the same indignities seems pertinent here: Is this really the bar that needs to be met to demonstrate full mental capabilities?

 

Well, according to those who study dementia and other mental deterioration, yes.

 

In 2009, I spent six months serving on a jury in the state of New York that was asked to judge the guilt or innocence of a man named Anthony Marshall. Marshall was the son of Brooke Astor, a New York socialite and heiress to the much-diminished Astor fortune. If you’ve ever traveled to New York, you’ve encountered the name: Astor Place, the Waldorf-Astoria or the Astoria neighborhood in Queens. Marshall was accused of having taken advantage of Astor’s diminished mental state to change her will without her being aware of the changes made. Ultimately, the 12 members of the jury found Marshall guilty of several charges.

 

Over the course of that trial, we were presented with a great deal of information about how doctors assess the mental capabilities of a patient. This was critical to the prosecution; were they not able to prove that Astor’s mental state was diminished, it undercut their argument that Marshall had acted without his mother’s consent. As such, expert witnesses testified about their personal examinations of Astor and others spoke to the reliability of the tests.

 

Central to that case was one of the components of the MoCA test: drawing a clock. Astor was asked repeatedly to draw analog clocks as a test of her mental acuity. On more than one occasion, she was unable to do so properly. . . . 

 

The point is not that the test is easy. The point is that an inability to complete aspects of the test reveals different types of mental decline. The clock test is about executive brain function: memory, planning ahead. The different parts of the MoCA are labeled according to what they test, with the clock test falling under “visuospatial/executive.” Questions about the current year and date are under “orientation.” The request to identify a drawing of a camel is under “naming.” In the test’s scoring instructions, it explains what is covered: “attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations and orientation.”

 

It is, as Trump’s doctor noted, a tool for identifying early signs of mental deterioration, like the mental version of a blood sample on which your doctor runs a battery of tests. It’s not the SAT; it’s a screening device.

For more, read Why You May Be Misunderstanding the Mental Test that Trump Passed with Flying Colors, by Philip Bump.

January 17, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Discrimination, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Science | Permalink | Comments (0)

Thursday, December 28, 2017

Dementia Therapy in German Nursing Home

A German nursing home is turning back the hands of time in an effort to better treat residents with dementia. The Washington Post story, A German nursing home tries a novel form of dementia therapy: re-creating a vanished era for its patients, explains how rather than trying to help residents remember, the facility takes them back to a specific period of time when they were younger.  For example one "nursing home ...  is trying to trigger [resident] ... memories by re-creating settings from [a prior] era as a form of therapy. While other nursing homes are also trying to help their residents remember details of their lives, what is going on here could well be the only concerted effort to re-create for its residents an entire historical era." This includes providing residents with tools they used in their jobs-but this only works if they liked their jobs, according to the article. Items are placed in "a memory room" for residents to visit.  The staff had to become knowledgeable about the time period in order to appear as an authentic residents of the era. So far the facility focuses on two decades with plans to expand to encompass a third decade.

Thanks to my colleague, Professor Mark Bauer, for alerting me to the article.

December 28, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, International | Permalink

Elder Caregiving and Women Not in the Workforce

For regular readers of this blog, it's no surprise that we have written on several occasions about family caregivers and the upcoming shortage of caregivers as the boomers age.  Professor Naomi Cahn called this New York Times article to our attention (thanks Naomi),  How Care for Elders, Not Children, Denies Women a Paycheck looks at why more women aren't in the workforce. "[T]he consensus is incomplete. It misses perhaps the most significant impediment to women’s continued engagement in the labor market, one that is getting tougher with each passing year: aging. Focused laserlike on child care, we haven’t noticed that the United States is walking into an elder-care crisis." The article offers sobering statistics and as we know, in many instances the family caregiver is the female.

About a quarter of women 45 to 64 years old and one in seven of those 35 to 44 are caring for an older relative, according to the American Time Use Survey. ... It takes a toll. Ten percent of caregivers have to cut back on their hours at work; 6 percent leave their jobs entirely, according to a report last year by the National Association of Insurance Commissioners.... A 2015 survey by the insurer Genworth Financial found that caregivers spend about 20 hours a week providing care — about half what a full-time worker would spend at work. Almost four in five said they had missed work, and about one in 10 lost a job. One in six reported losing around one-third of income because of caring responsibilities.

Thinking ahead to another generation, the Millennials face an even greater task.

Unlike the boomers now taking care of their parents, their millennial children will not have as many siblings to help care for their parents. Higher divorce rates imply that many aging boomers will have no spouse to care for them, putting additional demands on their children. And the elderly of the future are going to live longer, which suggests there will be a lot of caregivers well into their 50s juggling work with care for their children and their parents.

How this issue will be solved, or resolved, will likely fall to the states. "And if prime-age women start leaving the work force in even higher numbers to care for their aging parents, this will also be a problem for the American economy."

December 28, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Health Care/Long Term Care | Permalink | Comments (0)

Thursday, December 14, 2017

Polypharmacy: an ongoing problem

There's been a lot of attention of late regarding the very serious opiod crisis. But I think it's important to keep in mind the issue of polypharmacy and elders. The Washington Post ran this article, The other big drug problem: Older people taking too many pills, which opens with this "[c]onsider it America’s other prescription drug epidemic." The article offers sobering statistics

Researchers estimate that 25 percent of people ages 65 to 69 take at least five prescription drugs to treat chronic conditions, a figure that jumps to nearly 46 percent for those between 70 and 79. Doctors say it is not uncommon to encounter patients taking more than 20 drugs to treat acid reflux, heart disease, depression or insomnia or other disorders.

In fact, some elders have health issues from polypharmacy, some which are preventable,  according to the article. The polypharmacy problems can create a vicious cycle for some folks for whom  "the side effects of drugs are frequently misinterpreted as a new problem, triggering more prescriptions, a process known as a prescribing cascade." Often, a hospitalization and new meds on top of the existing ones contribute to the problem.  Evidently the problem of polypharmacy, although not new, is increasing.  The article explains that some doctors are engaging in what is referred to as "deprescribing" which is explained as "systematically discontinuing medicines that are inappropriate, duplicative or unnecessary." The article explains a number of hurdles to this goal, including lack of research, time constraints, advertising and just changing the status quo.

This is a really interesting article and worth the read!

December 14, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Health Care/Long Term Care, Other | Permalink | Comments (0)

Good Friends-More Important than You Think.

I recall a children's song I learned about the importance of keeping your old friends while making new friends.  So the Kaiser Health News story about friends caught my eye. Good Friends Might Be Your Best Brain Booster As You Age reports on a new study from Northwestern regarding the connection between "brain health and positive relationships." The Northwestern Study, Psychological well-being in elderly adults with extraordinary episodic memory is an open source article available as well as a pdf.  Here is the abstract from the study

The Northwestern University SuperAging Program studies a rare cohort of individuals over age 80 with episodic memory ability at least as good as middle-age adults to determine what factors contribute to their elite memory performance. As psychological well-being is positively correlated with cognitive performance in older adults, the present study examined whether aspects of psychological well-being distinguish cognitive SuperAgers from their cognitively average-for-age, same-age peers.

Want to live longer and happier, then be nice to your good friends (maybe call them up now and tell them hi!). The article's concluding summary offers this

SuperAgers endorse higher levels of Positive Relations with Others compared to their cognitively healthy but average-for-age same-age peers suggesting that this aspect of psychological well-being may be an important factor for exceptional cognitive aging. Investigation of the longitudinal effects of psychological well-being on subsequent cognitive performance and investigation of the conceivable relationship between psychological well-being and von Economo neurons in SuperAgers represent intriguing future directions.

 

December 14, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Health Care/Long Term Care, Other | Permalink | Comments (0)

Wednesday, December 13, 2017

"Snake Oil," Tattoos & Why Some Hospice Doctors Prefer Medical Powers of Attorney

Are games and food supplements that promise to stave off the onset of dementia the modern day version of "snake oil?" I promised to write more about the Aging Brain Conference at Arizona State University's Sandra Day O'Connor College of Law on December 8, 2017.  Speaker Dr. Cynthia Stonnington, Mayo Clinic, offered an important look at ways in which law, ethics, medicine, and commerce can collide with her survey of a host of approaches receiving "popular" press treatment.  

She examined self-described "brain-training" programs, miracle diets, supplements and targeted exercise programs, noting that most studies that purport to demonstrate positive results from these items have serious flaws.  Thus, at best, programs that claim to provide "protection" against dementia are usually promising more than has been proven.  Dr. Stonnington, along with the morning keynote speaker, former U.S. Surgeon General Richard Carmona, reminded us that

  • maintaining social engagement,
  • engaging in lifelong learning,
  • getting regular exercise of any type,
  • having good blood pressure control,
  • getting adequate sleep, and
  • focusing on good nutrition (including eating plans such as the Mediterranean, DASH or MIND diets)

are  far more important than any single, magic game or exercise.

One of the most lively discussions of the day came near the end, in response to presentations by Dr. Patrica Mayer of Banner Health in Phoenix, Amy McLean of Hospice of the Valley. and Life Sciences Professor Jason Robert (ASU) speaking for himself and Susan Fitzpatrick (James S. McDonnell Foundation), about end-of-life considerations for persons with dementia or other serious illnesses.  What would be the most likely response of a physician or emergency personnel confronted with a "do not resuscitate" tattoo on the chest of an emergency patient?  Dr. Mayer stressed that she is seeking reliable methods of communicating end-of-life wishes, and for her that means a preference for a written, Medical Power of Attorney.  She wants that "live" interaction whenever possible, in order to fully explore the options for care for individuals unable to communicate for themselves.  But she also noted a frequent frustration when she contacts designated  POAs about the need to make tough decisions, only to learn they were completely unaware before that moment of having been named as the designated agent.  

LSI_Aging Brain 120817 Competency_and_Incapacity_1 SPEC (1)I was part of a panel of court-connected speakers, including Arizona Superior Court Judge Jay Polk (Maricopa County), neuropsychologist  (and frequent expert witness) Elizabeth Leonard, and experienced Phoenix attorney Charles Arnold.  I was interested to hear about  -- and will pursue more information on -- the psychologists' use of evaluative tools for clients that use scenarios that would appear to test not just for loss of memory, but impaired judgment.  I was speaking on the unfortunate need for judicial inquiries into "improvident transactions" by persons with problematic cognition and I used litigation approaches from other locations -- Ireland (common law) and Maine (statutory) -- as examples.  The Arizona legal experts reminded me to take a closer look at Arizona's financial exploitation laws.

For more from this conference, see Learning to Say the Word "Die"  --  about a pilot program developed by Dr. Mayer while she was an advanced bioethics fellow at the Cleveland Clinic.  I also recommend Dr. Mayer's article on CPR & Hospice: Incompatible Goals, Irreconcilable Differences

 

December 13, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Games, Health Care/Long Term Care, Legal Practice/Practice Management, Programs/CLEs, Science, Statistics | Permalink | Comments (0)

Tuesday, December 12, 2017

Legal Implications of Biomarkers for Dementia Highlight ASU's Conference on "The Aging Brain"

The "Aging Brain" Conference hosted by Arizona State University's Sandra Day O'Connor College of Law held on December 8, 2017 at the Sandra Day O'Connor United States Courthouse in Phoenix (that's a double helping of Sandra!) proved to be a fascinating, deep dive into the intersection of medicine, ethics and law with a focus on neurocognitive diseases, including Alzheimer's Disease.  The panelists and audience included academics in a wide range of fields, plus practitioners in medicine, law, social services, and more, along with both state and federal judges.  United States District Judge Roslyn Silver is a long-time supporter of law and science programming with ASU. LSI_Aging Brain 120817 Competency_and_Incapacity_5 SPEC (2)

One of the important themes that emerged for me was the growing significance of pre-symptomatic tests that can disclose genetic markers associated with greater incidence of an eventual, active form of a degenerative brain disease.  Neurologist Richard Caselli from Mayo Clinic and Jessica Langbaum, principal scientist with Banner Alzheimer's Institute laid out the latest information on a variety of genetic testing options, including the possibly mixed results for "risk" connected to positive results for specific genetic markers.  A provocative question by a morning speaker, Law and Biosciences Professor Henry T. Greely at Stanford, captured the personal dilemma well, when he asked the audience to vote on how many would want to to know the results of a genetic test that could disclose such a connection, especially as there is, as yet, no known cure or even any clear way to prevent most neurocognitive diseases from taking hold.  

Taking that a step further, how many of us would want our employer to know about that genetic marker results?  How about our health insurers? As we discussed at the conference, some consumer information is already available through "popular" ancestry testing sites such as "23 and Me," which expressly offers testing for "genetic health risks," including "late-onset Alzheimer's Disease and Parkinson's Disease."  Arizona State Law Professor Betsy Gray, director of the Law & Neuroscience Program for ASU's Center for Law, Science and Innovation, who master-minded the conference, helped to identify a host of legal and ethical issues connected to this developing world of science and medicine. Jalayne J. Arias, a full-time researcher at University of California San Francisco's Neurology, Memory and Aging Center (and clearly a rising academic star and graduate of ASU Law) outlined the implications of pre-symptomatic testing from the perspective of long-term care insurance.  For more from Professor Arias, I recommend her 2015 paper for the Journal of Clinical Ethics on Stakeholders' Perspectives on Preclinical Testing for Alzheimer's Disease.

 I plan to write more about this conference, as many perspectives on legal, ethical and medical questions were offered.      

December 12, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Discrimination, Ethical Issues, Programs/CLEs, Science | Permalink | Comments (0)

Wednesday, December 6, 2017

Arizona State Presents Legal, Policy and Ethical Perspectives on "The Aging Brain"

On December 8, 2017, I'm excited to be participating in a conference on The Aging Brain: Legal, Policy & Ethical Perspectives, in Phoenix, Arizona.  This program is a follow-up to an interdisciplinary workshop hosted at Arizona State University's Sandra Day O'Connor School of Law in the fall of 2016. This year's presentations will take place at the the United States Courthouse in Phoenix.

The planned schedule is jam-packed with speakers I'm looking forward to hearing, including:

Welcome: Betsy Grey, Sandra Day O’Connor College of Law, ASU

Introduction: Dean Douglas Sylvester, Sandra Day O’Connor College of Law, ASU

Keynote Speaker:Richard H. Carmona, M.D., M.P.H., FACS, 17th Surgeon General of the United States, Chief of Health Innovations, Canyon Ranch, Distinguished Professor, University of Arizona

Scientific Developments in Aging and Dementia: Pre-Symptomatic Screening for Neurodegenerative Diseases

    Panel Chair: Hon. Roslyn O. Silver, U.S. District Court for the District of Arizona

  • Dr. Richard Caselli, Mayo Clinic
  • Dr. Jessica Langbaum, Banner Alzheimer's Institute
Ethical, Legal, and Social Implications
       Panel Chair:  Michael Saks, Sand Day O'Connor College of Law
  • Dr. Cynthia M. Stonnington, Mayo C;inic
  • Jalayne J. Arias, UCSF Neurology, Memory and Aging Center
  • Henry T. Greely, Stanford Law School

Aging at Home

    Panel Chair: Larry J. Cohen, The Cohen Law Firm

  • David Coon, College of Nursing & Health Solutions, ASU
  • Kent Dicks, Life365, Inc.
Competency and Incapacity: Assessment and Consent

    Panel Chair: Charles L. Arnold, Frazer Ryan Goldberg & Arnold, LLP

  • Hon. Jay M. Polk, Probate Dep’t. Associate Presiding Judge, Superior Court of Arizona for Maricopa County
  • Katherine Pearson, Dickinson School of Law, Pennsylvania State University
  • Dr. Elizabeth Leonard, Neurocognitive Associates
  • Betsy Grey, Sandra Day O’Connor College of Law, ASU

End of Life

    Panel Chair: Dr. Mitzi Krockover, Health Futures Council at ASU

  • Jason Robert, Lincoln Center for Applied Ethics, ASU
  • Amy McLean, Hospice of the Valley
  • Dr. Patricia A. Mayer, Banner Baywood & Banner Health Hospitals

Keynote:

Dr. Susan Fitzpatrick, President, James S. McDonnell Foundation
Introduction by Jason Robert, Lincoln Center for Applied Ethics, ASU

December 6, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Federal Cases, Health Care/Long Term Care, Science, Statistics | Permalink | Comments (0)

Thursday, November 30, 2017

Questions Arise With Evictions of Residents from Continuing Care (Life Plan) Communities

Recently I wrote about a high profile suit filed by AARP attorneys on behalf of residents at a California skilled care (nursing home) facility to challenge evictions.  

I've also been hearing about more attempts to evict residents from  Continuing Care Communities, also known as CCRCs or Life Plan Communities.   For example, in late 2016 a lawsuit was filed in San Diego County, California alleging a senior's improper eviction from a high-end CCRC.  The woman reportedly paid a $249k entrance fee, plus additional monthly fees for 15 years.  When she reached the age of 93, however, the CCRC allegedly evicted her for reasons unconnected to payment. The resident's diagnosis of dementia was an issue.  Following negotiations, according to counsel for the resident, Kelly Knapp, the case reportedly settled recently on confidential terms.  

Is there a trend?  Are more CCRC evictions happening, and are they more often connected to a resident's diagnosis of dementia and/or the facility's response to an increased need for behavioral supervision?  If the answer is "yes," then there is a tension here, between client expectations and marketing by providers.  Such tension is unlikely to be good news for either side.    

CCRCs are often viewed by residents as offering a guarantee of life-time care. Even if any promises are conditional, families would not usually expect that care-needs associated with aging would be a ground for eviction.  

The resident and family expectations can be influenced by pricing structures that involve substantial up-front fees (often either nonrefundable or only partially refundable), plus monthly fees that may be higher than cost-of-living alone might explain.  Marketing materials -- indeed the whole ambiance of CCRCs -- typically emphasize a "one stop shopping" approach to an ultimate form of senior living.      

In one instance I reviewed recently, the materials used for incoming residents explained the pricing with a point system. The prospective resident was told that in addition to the $100+k entrance fee, an additional daily fee could increase as both "medical and non-medical" needs increased.  A resident who "requires continual and full assistance of others . . . is automatically Level C" and billed at a higher rate. The graded components included factors such a need for assistance with "cognition, mood, or behavior," or "wandering."  All of that indicates dementia care is part of the "continuing" plan.

CCRCs, on the other hand, may turn to their contract language as grounds for an eviction. Contracts may have language that attempts to give the facility sole authority to make decisions about a resident's "level" of care.  Sometimes that authority is tied to decisions about "transfers" from independent living to assisted living or to skilled care units within the same CCRC, as the facility sees care needs increasing.  Even same-community transfer decisions can sometimes be hard for families. Complete evictions can be even harder to accept, especially if it means a married couple will be separated by blocks or even miles, rather than hallways in the same complex.

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November 30, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Medicare, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (1)

Sunday, November 26, 2017

Canadian Centre for Elder Law New Report on Vulnerable Investors

The Canadian Centre for Elder Law (CCEL) released a new report, Report On Vulnerable Investors: Elder Abuse, Financial Exploitation, Undue Influence And Diminished Mental Capacity, which can be downloaded as a pdf here. The report was a joint project between CCEL and FAIR (Canadian Foundation for Advancement of Investor  Rights). Here is the executive summary of the report

Canadian investment firms and their financial services representatives1 (hereinafter referred to as "financial services representatives" or simply "representatives") serve millions of vulnerable investors, many of whom are older Canadians. Vulnerable investors may be persons living in isolated, abusive or neglectful situations which can make them more likely to be subject to undue influence. They also may be persons with diminished mental capacity due to health issues, developmental disability, brain injury or other cognitive impairment. Such social vulnerabilities may be episodic, or long-term.2

Who is a Vulnerable Investor?

Older investors, persons with fluctuating or diminished mental capacity, and adults who are subject to undue influence or financial exploitation are collectively referred to in this report as vulnerable investors. This concept of vulnerability is often a contentious one. This report uses the term "vulnerable" to refer to social vulnerability, and does not ascribe vulnerability to older persons as an inherent personal characteristic.3 Rather, the term reflects an understanding that differing social conditions may make a person more or less vulnerable. Individual older investors may personally not be socially vulnerable. But as a group, older individuals may be subject to external conditionssuch as ageismthat negatively affect them. This report specifically notes that ageism can make older people broadly vulnerable as a class, even while individual older adults may not be, or identify, as particularly vulnerable themselves.

This report adopts the core aspects of the Quebec definition of vulnerable investor. A vulnerable investor is a person who is in a vulnerable situation, who is of the age of majority, and lacks an ability to request or obtain assistance, either temporarily or permanently, due to one or more factors such as a physical, cognitive or psychological limitation, illness, injury or handicap.

It is important, and a goal of this report, to highlight the increased social vulnerability risks associated with aging and to raise awareness that aging life-course benchmarks may trigger a representative to start ensuring that increased appropriate protections or standards are in place. In this way, the issue of older investors will be drawn to the fore, without supporting the myth that all old people are vulnerable and in need of protection.


 
 

November 26, 2017 in Cognitive Impairment, Consumer Information, Crimes, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, International | Permalink | Comments (0)

Actions by Attorneys and Their Investigators Trigger Sanctions Affecting the Underlying False Claims Act Suit

A decision earlier this year in a qui tam suit, alleging the submission of false claims to Medicare for the off-label prescription of a drug for dementia, seems especially interesting in light of recent high profile allegations involving Harvey Weinstein's alleged use of private investigators to befriend his victims  in order gather information.  

In the qui tam suit the drug in question was Namenda, described in the opinion as "approved by the FDA  for treatment of moderate to severe Alzheimer's disease," but allegedly also promoted illegally by the companies for prescription to individuals with milder stages of dementia.  In Leysock v. Forest Laboratories, et al, the United States District Court in Massachusetts dismissed the complaint as a sanction for conduct by the plaintiff's attorneys and the investigator hired by those attorneys:  

The present dispute arises out of the conduct of counsel for relator, the Milberg law firm, in investigating the case. As set forth below, Milberg attorneys engaged in an elaborate scheme of deceptive conduct in order to obtain information from physicians about their prescribing practices, and in some instances about their patients. In essence, Milberg retained a physician and medical researcher, Dr. Mark Godec, to conduct a survey of physicians concerning their prescription of Namenda to Medicare patients. In order to obtain the cooperation of the physicians, Dr. Godec falsely represented that he was conducting a medical research study. Dr. Godec, at Milberg's direction, conducted two internet-based surveys as well as follow-up telephone interviews. Among other things, the physicians were induced to provide patient medical charts and other confidential medical information to Dr. Godec. Information derived from those surveys was then set out in the Second Amended Complaint in this action, and was relied on by the Court in denying defendant's motion to dismiss in 2014.

 

Defendants have now moved to dismiss the Second Amended Complaint as a sanction for alleged violations of attorney ethical rules. For the reasons stated below, that motion will be granted.

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November 26, 2017 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)