Wednesday, December 4, 2013
Writer Kim Severson at the New York Times reports on the death of 72-year old Ronald Westbrook, shot by Georgia homeowner Joe Hendrix after trying to gain entrance to Hendrix's home:
"In the confusion that comes from Alzheimer’s, Mr. Westbrook had taken to collecting the mail from neighbors’ mailboxes. He was doing so that night on Marbletop Road, which is a mile or so from his home. He told the deputy he lived in a nearby house, which at one time, years ago, he had. 'Better get home,' the deputy said. 'It’s cold.'
The deputy drove on, and Mr. Westbrook, in a straw hat and a jacket too light for the weather, continued walking with his dogs. Just before 4 a.m., he was nearly three miles from home in the subdivision of modest new houses where Mr. Hendrix lives, near Chattanooga."
While the NYT story focuses mostly on the fear, confusion, and potential impact of Stand Your Ground laws, as factors potentially contributing to the older man's death, I am reminded of another story I blogged about earlier, where a wandering man with early onset dementia ended up in jail, only to suffer a brutal beating at the hands of a cellmate when authorities failed to recognize the implications of the man's confusion. Ironically, that case too was in Georgia.
In both instances, it seems that public authorities arguably had a chance to shepherd their wandering citizens to a safer setting.
Tuesday, November 26, 2013
Via Yahoo News:
A man from Leeds, England has invented a dog-controlled washing machine. The "Woof to Wash" machine has a bark-activated "on" switch. A special "paw" button allows the pooch to easily open and close the machine's door. The inventor, John Middleton of U.K. laundry company JTM, intends for the "Woof to Wash" machine to make laundry an easier task for people living with disabilities by letting them delegate the trickier parts of the job to support dogs who have been trained to load and empty the machines. "We developed this machine because mainstream products with complex digital controls seldom meet the needs of the disabled user," he said. The Sheffield charity Support Dogs is training the animals to operate the new machines.
"People who are visually impaired, have manual dexterity problems, autism or learning difficulties can find the complexity of modern day washing machines too much," Middleton told Anorak. "I had been working on a single program washing machine to make things easier, and there was a lot of demand for it."
Sunday, November 24, 2013
"Do Not Hospitalize" is the latest initiative in advance care directives, driven by emerging recognition of the variety of ways that individuals may not be well served by extra-ordinary care measures, requiring specific directions. The concept may require lawyers drafting traditional living wills to think more broadly. Further, the concept highlights the importance of families working directly with physicians who are sensitive to the larger dynamic.
I have to say this one hits home in my own family. My father, after physical health problems combined with larger frailty, declared at age 86, "I would rather die on the steps of the hospital" than spend another night there. That has been hard, at times, for my family to accept.
The New York Times in Judith Graham's "A Misunderstood Directive," provides a back story for the use of DNH orders. Dr. Michael Rothberg describes what occurred after his father-in-law, with severe dementia, was transferred from a care facility to a hospital for evaluation, a move that triggered even greater disorientation and reaction by the man, leading to restraints and medication. The theory of DNH is to provide a reasoned basis not to see hospitalization as the only option for patients, especially those with dementia:
"After another difficult hospitalization, this time for pneumonia, the family decided they didn’t want this vulnerable, distressed relative transferred from the nursing home again if he took ill. They asked that a “do not hospitalize” order be communicated to staff and placed in his medical record. Several months later, the patient stopped eating and drinking and passed away."
Dr. Rothberg and colleagues in Pennsylvania and Massachusetts have collaborated on a paper to describe and evaluate Do Not Hospitalize directives entered into by authorized agents (health care proxies or HCPs) for individuals with advanced dementia. They conclude:
"The potential barriers to and facilitators of HCPs initiating DNH orders identified in this study suggest that HCPs may benefit from more in-depth discussions with healthcare providers when making this decision. Interventions to address these barriers may improve the capacity of HCPs to make informed decisions about DNH orders that reflect individuals' values and wishes."
Friday, November 22, 2013
Via the Japan Times:
Humanitude, a caregiving method developed in France that emphasizes eye contact, touch and verbal communication to convey respect for the patient as a human being, is gaining attention in Japan for treating patients with dementia. Tokyo Medical Center in Meguro Ward, one of the hospitals adopting the Humanitude method, provides seminars for caregivers to expand its use. In a videotape shown at one such seminar, two nurses took a female patient with dementia to a shower. One nurse approached the woman from the front, looked at her at eye level and kept speaking to her gently while the other nurse washed her body with warm water.
The woman in her 70s, who was said to have screamed and refused to take a shower, was cooperative and remained calm, and even said that “the water temperature feels good.” The approach, with its name deriving from “human” and “attitude,” was developed about 30 years ago by Yves Gineste, who taught physical education, and his colleagues based on the philosophy of “what is humanity.”
The four basic pillars in the method are to look into the eyes of the patients, talk to, touch and help them stand upright. More specifically, particularly for elderly people with dementia, this means approaching from the front to avoid startling the patients, who tend to have a narrow range of vision; looking at them at eye level; telling them the procedures being conducted even if there is no response; avoiding gripping the patients’ wrists from above; and helping them stand upright or walk. There were remarkable scenes in the videotape that were taken in February last year when Gineste visited Tokyo Medical Center.
Wednesday, November 13, 2013
I’m at the conference on International Elder Law with Emphasis on Veterans Benefits (it is excellent, by the way). The host is Professor Jim Pietsch, Director of the U. of Hawaii Elder Law program. Jim has done a number of innovative programs throughout his tenure at the law school. One of these programs I’ve always found so clever is the “Nite of the Living Will” where the students do advance directives for elder Hawaiians on Halloween. How clever is that?
We do Wills for the Greatest Generation (a take-off on “Wills for Heroes”) where our students work with attorneys who volunteer for the Community Law Foundation (the local pro bono panel) and the St. Petersburg Bar Foundation. They provide simple wills and health care directives for veterans and spouses from World War II, Korea and Vietnam. Like the Nite of the Living Will, it gives students some great practical experience in drafting and working with clients. (Our students do not get academic credit, but can get legal pro bono hours toward Stetson’s graduation pro bono requirement). I know we are not the only schools doing something like this, so let’s hear from you. What programs are offered at your schools?
Tuesday, November 12, 2013
A new report highlighting the need for urgent action to improve residential aged care includes case studies of people being shackled, assaulted, sedated against their wishes and turned into "zombies". Australian of the Year and Alzheimer's Australia national president, Ita Buttrose, today launched the report calling for good quality residential aged care to be the norm. Quality of Residential Care: the Consumer Perspective acknowledges there are dedicated, compassionate people who work hard to provide quality care but notes there are instances of poor quality care. In 2012 there were more than 220,000 people in Australia in residential aged care in more than 2700 facilities across the nation.
"What worries me is that a minority of facilities are not providing good care, and that residents are not being respected and, in some cases, are subjected to physical or psychological abuse," Buttrose said. "Since becoming president of Alzheimer's Australia many consumers have shared disturbing stories with me of physical, psychological and sexual abuse, inappropriate use of restraint, unreported assaults and people in extreme pain at end of life not having access to palliative care. "The objective of the report developed by Alzheimer's Australia is to articulate the concerns of consumers, set out for discussion possible strategies to address them and to seek a higher priority for tackling them.
"It proposes strategies to bring providers, staff and consumers together to address the systemic issues in the aged care system that have led to breakdowns in quality care. Funding issues are important but equally so are the leadership and culture that respects the rights and dignity of older people. Common decency and respect costs nothing."
Source: Brisbane Courier Mail
Sunday, November 10, 2013
So-called "Slayer Rules" bar a murderer from inheriting from his victim, and often apply not only to intestate succession but also to gifts made under wills or nonprobate transfers. The bar may arise by common law, often rooted in equity, or statute.
As Harvard Law Professor Robert Sitkoff summarizes well in his 9th edition (Dukeminier) of Wills, Trusts & Estates, "Nearly every state has enacted a statute dealing with the rights of a killer in the estate of a victim, but the details of these statutes vary considerably and often leave gaps to be resolved by the courts."
However, states have also been expanding the notion of "no profit" from wrongdoing to include abusers -- and theories regarding elder abuse appear to be part of the reason.
For example, in a 2013 case, the Washington Supreme Court analyzed application of a 2009 amendment of that state's slayer statute to include "abusers," defined as "any person who participates, either as a principal or an accessory before the fact, in the willful and unlawful financial exploitation of a vulnerable adult." The court concluded in a 5-4 decision that the date of filing of a petition to declare a beneficiary an abuser serves as the trigger for timing questions.
The Washington case involved allegations made by three surviving children against their father's second wife. The father was in his late eighties when he married the younger woman, who was younger by fifty years. The history of the case includes a discussion of the father's dementia, and allegations the wife made large transfers to herself and others before his death. See In re Estate of Haviland, 301 P.3d 31 (Wash. 2013).
In 2012, Michigan amended its slayer statute to include abusers, as part of a series of changes to state laws reportedly intended to provide better protection for elderly and vulnerable adults. Cooley Law Professor Linda Kisabeth analyzes the Michigan changes in her recent article "Slayer Statutes and Elder Abuse: Good Intentions, Right Results? Does Michigan's Amended Slayer Statute Do Enough to Protect the Elderly?" in 26 Quinnipiac Prob. L. J. 273 (2013).
And for an interesting alternative take on slayer laws in their more traditional application, to "murderers," see the 2013 article by Professor Carla Spivack (Okla.City Law), "Killers Shouldn't Inherit From the Victims -- Or Should They?"
Hat tip to Professor Harvey Feldman for pointing the way to the Washington case.
November 10, 2013 in Cognitive Impairment, Crimes, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, State Cases, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)
Wednesday, November 6, 2013
Earlier this week, I wrote about caregiver risk in home settings. By coincidence, a recent issue of GSA's Journals of Gerontology, includes "Predictors of Dementia Caregiver Depressive Symptoms in a Population: The Cache County Dementia Progression Study," by Kathleen W. Piercy and others.
By focusing on factors that correlate with depression in caregivers, the article would also seem to be identifying potential risks factors for caregivers to neglect or otherwise be unable to provide proper care for individuals with dementia.
The article opens with a straight-forward (and useful) history of literature on caregiver depression. The team's research, drawn from a longitudinal study of individuals with dementia plus 256 of their caregivers, was somewhat reassuring in that depression rates were lower than might be predicted from "clinic-based studies." Nonetheless, their research pointed to the importance of support networks for caregivers, and the potential impact of "emotion-focused coping styles, poorer health, low quality of life," and whether the individuals were caring for persons with high behavioral problems, as factors correlating with depression in caregivers. The authors are careful to identify the limitations of their study, including caution about inferring causation.
Wednesday, October 9, 2013
Via the BBC:
The discovery of the first chemical to prevent the death of brain tissue in a neurodegenerative disease has been hailed as an exciting and historic moment in medical research. More work is needed to develop a drug that could be taken by patients. But scientists say a resulting medicine could treat Alzheimer's, Parkinson's, Huntington's and other diseases. The University of Leicester discovery showed all brain cell death from prion disease in mice could be prevented.
The research team at the university's Medical Research Council Toxicology Unit focused on the natural defence mechanisms built into brain cells. When a virus hijacks a brain cell it leads to a build-up of viral proteins. Cells respond by shutting down nearly all protein production in order to halt the virus's spread. However, many neurodegenerative diseases
involve the production of faulty or "misfolded" proteins. These activate the same defences, but with more severe consequences.
The misfolded proteins linger and the brain cells shut down protein production for so long that they eventually starve themselves to death.
It is rare to get cautious scientists keen to describe a study in mice as a turning point in treating Alzheimer's. It is early science, a lot can go wrong between a drug for mice and a drug for humans and the only published data is for prion disease, not even Alzheimer's. So why the excitement?
It is the first time that any form of neurodegeneration has been completely halted, so it is a significant landmark. It shows that the process being targeted has serious potential. If this can be successfully developed, which is not guaranteed, the prize would be huge. In Parkinson's the alpha-synuclein protein goes wrong, in Alzheimer's it's amyloid and tau, in Huntingdon's it's the Huntingtin protein. But the errant protein is irrelevant here as the researchers are targeting the way a cell deals with any misfolded protein. It means one drug could cure many diseases and that really would be something to get excited about.
Tuesday, October 8, 2013
The Center for Law, Brain and Behavior (CLBB) at Massachusetts General Hospital (MGH) has a fascinating sounding project underway: using neuroscience to develop tools to evaluate human susceptibility to undue influence. Here's a brief description from a recent MGH newsletter:
"A second CLBB project focuses on older adults with cognitive impairment who are at heightened vulnerability to coercion by opportunists hoping to control their decisions, particularly concerning financial matters. The goal of the study is to devise and test a psychometric instrument to measure susceptibility to undue influence that can be used in proceedings about guardianship, testamentary capacity and informed consent.'The development of this tool will make an immediate contribution to the protection of adults with mild to severe intellectual impairments,' says Dr. Price."
Hat tip to Ross Schmucki, Esq. of Media, Pennsylvania for sharing this news.
Friday, September 27, 2013
For example, I just finished teaching a series of cases that ask students to evaluate the voidability of large end-of-life gifts made by older individuals, usually to persons who appear to be caregivers or recent "befrienders." Were the transactions voluntary even if unwise, or were they the product of an unstable mind or undue influence? Close calls on most of the cases.
The cases that interest me most were the ones where an attorney represented the older person during execution of the documents. In one case, the court commented that the attorney who completed the transaction met with the new client for an hour on a Sunday afternoon and performed a series of "tests" that satisfied the attorney about the client's capacity to complete transfers of the bulk of his real estate. However, a geriatric psychiatrist who later evaluated the same individual, found the individual to have advanced dementia of an Alzheimer's Disease type and concluded the individual would not be able to understand the significance of the deed transfers signed earlier, even though he appeared to be "oriented as to time, place, and person."
Which professional's testimony carried the day? The court credited the attorney's testimony that his client was "lucid" while completing the documents in question, and pointed to the fact the doctor "conceded" that the individual had "moments of lucidity."
Exactly what "tests" does a lawyer, any lawyer, use to evaluate cognitive function? Perhaps every seasoned lawyer has a series of tried and true questions or techniques. But I suspect that many lawyers rely more on instinct than tests, and certainly most transactions by older adults are not challenged.
Should lawyers go further to assess capacity? To help frame the discussion on whether and when to go more deeply into questions of capacity, guidelines are available. Members of the American Bar Association (ABA) and the American Psychological Association (APA) participated in an interdisciplinary task force, which led to three separate documents, including worksheets that may be useful in any assessment of capacity:
- Assessment of Older Adults with Diminished Capacity: A Handbook for Lawyers
- Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
- Judicial Determination of Capacity of Older Adults in Guardianship Proceedings: A Handbook for Judges
The good news is that all three documents are available on the internet. The less good news is the documents are copyrighted and permission is needed to make additional copies for distribution to a group or audience. The handbooks have been available since 2006. Nonetheless, I suspect most attorneys, many psychologists, virtually all other medical professionals, and a heck of a lot of judges have never heard of the handbooks.
Any opinions about the usefulness of these handbooks to practitioners?
Friday, September 20, 2013
Last summer, great friends from Ireland were visiting in Pennsylvania. At the end of an evening's gathering, Clare, Joe or one of their sons would often wish me "Safe home." What a warm salutation -- for everyone.
Thinking more about the Goodman case from my earlier blog post, one question is whether all options were explored by the police, short of arrest. It is hard to accept that the man's arrest for "loitering" was the only solution available. Here was an individual whose confusion and late night wandering merely led him to the wrong house. In many jurisdictions, including the state in question, the crime charged, loitering, has been held unconstitutional as applied. But however wrong the crime charged in this case, shouldn't there be better options for "safe home?"
At least one option does exist: MedicAlert joined with the Alzheimer's Association to offer "Safe Return," a 24-hour emergency response service for persons with Alzheimer's or other cognitive impairments. The program works in two directions: The worried family member or caregiver can call a toll-free number to report the missing person, providing a source of reliable information for law enforcement about the individual's condition, health concerns and family. Plus, anyone encountering a wanderer who is wearing a MedicAlert bracelet or other ID can call the same toll-free number, thus initiating return to the "safe home."
The MedicAlert+Alzheimer's Association's Safe Return program (names are trademarked) charges an initial fee for the identification jewelry and registration, plus a smaller annual renewal fee. (Any possibility for a lower initial fee for those in need?) Perhaps health care professionals and elder law attorneys could offer this type of information to families during initial appointments.
Tuesday, September 17, 2013
While preparing for a Neurology Grand Rounds presentation on "Dementia and the Law" at Penn State Hershey, I read the 11th Circuit's decision in Goodman v. Kimbrough, affirming summary judgment in favor of defendant jail officials. The June 2013 decision in this civil rights claim has me asking questions. I suspect the case could provide opportunities for important discussion in a large number of law school courses. As our blogging partner Becky Morgan would say, an opportunity for teaching elder law "across the curriculum," although a pretty disturbing opportunity.
Basic facts: A 67-year-old man "suffering from dementia and prone to disorientation and confusion," was severely beaten by his cell mate while detained in a jail in Clayton County, Georgia. Why was he in jail? He apparently wandered away from his home at night, became confused, and "attempted to gain entry to another trailer." No indication in the opinion of breaking and entering. No indication in the opinion of violence. The man was "arrested for loitering and brought to the Jail." That bears repeating: "loitering."
The man's wife of more than 30 years, after awakening to find her husband gone, called 911 and learned of her husband's arrest. She went to the jail and "showed the officer at the second-floor desk her husband's medical records, explained that he was cognitively impaired and showing signs of dementia." Further, the wife:
"asked the officer to ensure that her husband received his medication and that he be placed either in the infirmary or in isolation so that he would not unintentionally insult another inmate and thereby come into harm's way."
While the timing of some events is not clear from the opinion, on the critical morning in question, when the jail officials opened the man's cell at 5 a.m. to deliver breakfast, they found him "covered in blood," with contusions on his face, eyes swollen shut, and the cell "laden with blood." His injuries were severe, requiring hospitalization in intensive care. Eventually, the jail's investigation determined the man had been beaten by his cell mate.
The 11th Circuit opinion criticizes the conduct of the jail guards in failing to make required hourly cell checks throughout the night and reportedly deactivating the emergency button of another detainee who testified he tried to alert the guards to the sound of the fight coming from the cell. In affirming summary judgment, the court concluded, however, that the plaintiff failed to offer the necessary evidence that the two guards "subjectively knew of a substantial risk of serious harm."
As I continue my preparation to talk with medical professionals about dementia and the law, I keep coming back to the question: "What if this man were your father or husband?" As our population ages and families struggle 24/7 to cope with dementia while keeping loved ones at home, we need better understanding of the condition at all levels. At a minimum there needs to be much better communication about dementia in the criminal justice system, especially if there is to be any justice from the system.
Thursday, September 5, 2013
Details on September as World Alzheimer's Month are available at the Alzheimer's Association's website. Three key steps anyone can take to support global awareness of the importance of research directed to ending Alzheimer's and providing support for caregivers are:
- Go Purple: Raise awareness by going purple to show your passion for the cause.
- Join a Walk: Be part of an event in your area to raise funds for care, support and research.
- Share Stories that Inspire: Alzheimer's Association offers stories of brave individuals who are making a difference in the fight to "#ENDALZ."
This week, NBC has been running a series on "The Age of Alzheimer's," hosted by Maria Shriver. The September 5 episode that aired on the Today Show told a heart-rending and (for me) disturbing story of a family, under the title "Alzheimer's Extracts a High Price on Caregivers, Too." Lots to talk about in classes after watching that episode!
Hat tip to Penn State Law student Katie Hagen for reminding me that September is World Alzheimer's Month!
University of California San Francisco (UCSF) researchers published a paper, made available this week in Nature, titled Video Game Training Enhances Cognitive Control in Older Adults. We can expect our students, children and grandchildren (not to mention game manufacturers) to remind us they were "right." From the abstract for the UCSF researchers' article:
Here we show that multitasking performance, as assessed with a custom-designed three-dimensional video game (NeuroRacer), exhibits a linear age-related decline from 20 to 79 years of age. By playing an adaptive version of NeuroRacer in multitasking training mode, older adults (60 to 85 years old) reduced multitasking costs compared to both an active control group and a no-contact control group, attaining levels beyond those achieved by untrained 20-year-old participants, with gains persisting for 6 months.
I suspect we will see a lot more on this area of research in the near future. Funding should be robust. Of course, I also suspect that not every game is equally helpful to cognitive enhancement and thus caution and consumer protections may be appropriate.
Monday, September 2, 2013
A gene associated with Alzheimer's disease in African-Americans was discussed in a recent issue of the Journal of the American Medical Association (JAMA). The JAMA report suggests lipid metabolism is an important pathway for late-onset Alzheimer's disease in African-Americans, a finding that parallels genetic research in individuals of European ancestry. The study was part of the analytical work of the Alzheimer's Disease Genetics Consortium, funded by a multi-million dollar 5-year grant from the National Institute on Aging.
The Consortium's website also offers background information on Alzheimer's disease, as well as reports on national and international research teams.