Thursday, June 1, 2017
Kaiser Health News ran an interesting story about the need for a team for aging. Putting In Place An A-Team Of Allies reports on elders who met to talk about those who would be "allies" going through the aging process, especially for those who have no nearby family. One participant, Mr. Gordon, described his allies system:
The setup has four tiers. In the first are three close friends who have powers of attorney for legal, financial and health care decision-making, should Gordon not be able to handle these responsibilities.
In the second are more than 25 friends and acquaintances whom Gordon — disabled by degenerative motor neuron disease — can call on for a ride to the doctor or a trip to the grocery store.
In the third tier are Gordon’s primary care doctor, lawyer and financial adviser, with whom he has close personal relationships. In the fourth are helpers he pays for services, including a driver and a handyman.
The article gives some examples of those who have organized their allies and recommendations for criteria in choosing allies.
Wednesday, May 24, 2017
Kaiser Health News ran a story about a series from the LA Times on Alzheimer's. The LA Times did a 3-part series on the brain and Alzheimer's. The first story focused on when the brain begins to be affected, the second about the benefits of exercise and the third about 8 items to do now to protect against dementia later. Some examples of those 8 items: exercise, eat right, don't smoke, get enough sleep, don't be isolated, be happy, and use your brain.
Monday, May 22, 2017
In what is described as a "first" for the National Academy of Elder Law Attorneys (NAELA), the organization through its New York Chapter will present argument on behalf of individuals seeking to establish access to "aid in dying." On April 27, the New York Chapter was granted leave to appear as amicus curiae in Myers v. Schneiderman before the New York Court of Appeals. Oral arguments are scheduled in Albany on May 30, 2017.
At issue is New York's penal law prohibiting assistance in "suicides." The original suit, filed in February 2015, sought a ruling that the statute, characterized by opponents as "antiquated," should be interpreted as not reaching the conduct of a physician that provides aid-in-dying where the patient is terminally ill and mentally competent and voluntarily seeks "terminal medication." Alternatively, the opponents of the law argue that the statute violates the rights of privacy and/or equal protection guaranteed by the New York State Constitution. New York's trial level court dismissed the challenge as a matter of law, on the grounds that New York's penal law was "clear on its face."
In joining the challenge to the dismissal, which was affirmed by appellate division, New York NAELA wrote:
As an organization of lawyers who represent the elderly and persons with disabilities, the New York Chapter [of NAELA] believes that a proper interpretation of New York's "assisted suicide" laws and due consideration of Appellants' constitutional challenges should be based on a fully developed factual record. These are issues of great moment to the elderly and those who love them and to the administration of justice in this State. This Court should have the benefit of a hearing and findings of relevant evidence before deciding them. . . .
What would assist this Court in fairly construing the Penal Law are facts relating to aid-in-dying. While the language of the statute is the starting point for interpretation, its words do not exist in a vacuum.
For more on the arguments, including links to the various parties' appellate briefs in Myers, see the "End of Life Liberty Project."
May 22, 2017 in Advance Directives/End-of-Life, Cognitive Impairment, Discrimination, Ethical Issues, Health Care/Long Term Care, Science, State Cases, State Statutes/Regulations | Permalink | Comments (0)
Monday, May 15, 2017
Here's a seven-minute video on elder financial abuse, focusing mostly on "scam artists," from the Pennsylvania Departments of Aging and Banking & Securities. You might find this useful for classes.
I found the discussion of "mild cognitive impairment" interesting, especially as it allows a conversation about planning without the dreaded words, dementia or Alzheimer's Disease.
May 15, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Film | Permalink | Comments (0)
Tuesday, May 9, 2017
Kaiser Health News ran a story about a boot camp for caregivers who care for those with dementia or Alzheimer's. ‘Boot Camp’ Helps Alzheimer’s, Dementia Caregivers Take Care Of Themselves, Too explains the importance of caregivers learning to take care of themselves while caring for others. The boot camp featured in the story hosted "25 people who went to a Los Angeles-area adult day care center on a recent Saturday for a daylong “caregiver boot camp.” In the free session, funded in part by the Archstone Foundation, people caring for patients with Alzheimer’s or another form of dementia learned how to manage stress, make their homes safe and handle difficult patient behaviors. They also learned how to keep their loved ones engaged, with card games, crossword puzzles or music." The article mentions the direct correlation between the caregiver's health and the care the provide to others.
UCLA's boot camp was started 2 years ago; the catalyst in part was the frequency of hospitalizations for those whose caregivers weren't ready for the job. UCLA currently offers 4 boot camps a year, but plans are underway to increase the number. California is not the only location for boot camps. Boot camps have taken place in Florida, New Jersey and Virginia.
Monday, April 24, 2017
Last week Kaiser Health News (one of my favorite go-to sites) ran this story, How To Help Alzheimer’s Patients Enjoy Life, Not Just ‘Fade Away’. The article opens explaining that Alzheimer's is #1 on the list of diseases folks in the U.S. most fear. The loss of self is a big part of that fear. However, "a sizable body of research suggests this Alzheimer’s narrative is mistaken. It finds that people with Alzheimer’s and other types of dementia retain a sense of self and have a positive quality of life, overall, until the illness’s final stages... They appreciate relationships. They’re energized by meaningful activities and value opportunities to express themselves. And they enjoy feeling at home in their surroundings."
Just how many folks with Alzheimer's have a good quality of life? According to Dr. Peter Rabins, "[o]verall, about one-quarter of people with dementia report a negative quality of life, although that number is higher in people with severe disease.” What are the implications of this? To make sure that folks with Alzheimer's have a quality of life, "[promote] well-being [which] is both possible and desirable in people with dementia, even as people struggle with memory loss, slower cognitive processing, distractibility and other symptoms."
Folks with severe or end-stage Alzheimer's present a different challenge. For others, the article suggests the following: emphasis social connections, maximize physical health, improve communications, respond to unmet needs, and give deference to individuality and autonomy.
"None of this is easy. But strategies for understanding what people with dementia experience and addressing their needs can be taught. This should become a priority, Rabins said, adding that 'improved quality of life should be a primary outcome of all dementia treatments.'"
Tuesday, April 11, 2017
The National Center on Elder Abuse released a new research to practice brief on Decision-Making Ability and Risk of Elder Mistreatment. This is the introduction to the brief:
There are many factors relevant to decision-making ability of older people including changes in the brain and cognition and social functioning. These changes can result in decision-making impairments that affect an older person’s ability to pay bills, drive, follow recipes, adhere to medication schedules, or refuse medical treatment (Braun & Moye, 2010; IOM, 2015). Decision-making ability may fluctuate at a given point in time (Falk et al., 2014), and while an older person may lack decision-making ability in one area, they may retain it in other areas (Braun & Moye, 2010). Decision-making ability is of special concern for the field of elder mistreatment because impaired decision-making can lead to an increased risk for abuse and exploitation among older people (Spreng et al., 2016). Thus, understanding the many factors relevant to decision-making ability is imperative to reduce risk of abuse and exploitation while maintaining and promoting autonomy among older people.
The 4 page brief covers key terms, explains how cognitive aging and capacity affect decision-making, the differences between medical decisional capacity and financial capacity and risk factors for financial exploitation. This would be great to use in our classes!
Monday, April 10, 2017
Alzheimer's & Dementia, the journal for the Alzheimer's Ass'n newest issue published a new report, Alzheimer's disease: The next frontier—Special Report 2017, A subscription is required but here is the abstract:
In the history of medicine, one means to progress is when we make the decision that our assumptions and definitions of disease are no longer consistent with the scientific evidence, and no longer serve our health care needs. The arc of scientific progress is now requiring a change in how we diagnose Alzheimer's disease. Both the National Institute on Aging—Alzheimer's Association (NIA-AA) 2011 workgroup and the International Work Group (IWG) have proposed guidelines that use detectable measures of biological changes in the brain, commonly known as biological markers, or biomarkers, as part of the diagnosis. This Special Report examines how the development and validation of Alzheimer's disease biomarkers—including those detectable in the blood or cerebral spinal fluid, or through neuroimaging—is a top research priority. This has the potential to markedly change how we diagnose Alzheimer's disease and, as a result, how we count the number of people with this disease. As research advances a biomarker-based method for diagnosis and treatment at the earliest stages of Alzheimer's disease, we envision a future in which Alzheimer's disease is placed in the same category as other chronic diseases, such as cardiovascular disease or diabetes, which can be readily identified with biomarkers and treated before irrevocable disability occurs.
Thursday, April 6, 2017
We all know that financial exploitation is a serious and significant problem in the U.S. I was interested in this article from Investment News detailing efforts that the financial services industry and others are taking to help their elder clients protect themselves from financial exploitation. Advisers taking steps to protect elderly explains although "[t]here's widespread acceptance in the financial services industry that elderly financial abuse is a growing problem, but there's no universally accepted game plan for how to respond... Many times firms' internal procedures will involve adviser education and training, and gathering third-party contact information for accounts." The article highlights the efforts of Wells Fargo Advisors which the article explains: "Wells Fargo launched an 11-member team more than two years ago within its compliance department that serves as an internal clearinghouse and case manager when advisers see a potential problem with a client. ... The unit has taken about 4,000 reports from the field, about half of which were incidences of abuse. Wells' Elder Care Initiatives often involves state adult protective services or securities regulators in the matters.:
Bank of America Merrill Lynch has also launched efforts to help protect their elder clients, according to the article. For example, one step Merrill Lynch has taken is to have "created a contact authorization form that gives advisers a trusted person to reach out to in case of suspected fraud or to obtain more information about behavioral changes linked to possible exploitation."
The article also highlights the efforts of Morgan Stanley, Charles Schwab, Edward Jones, and Fidelity Investments. As for smaller firms, they aren't lagging behind. For example, "[s]maller firms also are responding to the elder-abuse threat. For more than a year, Romano Wealth Management has had in place steps that its nine advisers follow in reporting potential abuse to the compliance officer, who then decides whether to involve adult protective services or regulators."
The article also discusses the efforts at the federal level. "The industry is starting to get protection from regulators. In February, the Securities and Exchange Commission approved a Financial Industry Regulatory Authority Inc. rule designed to curb elder abuse. It requires brokers to make “reasonable efforts” to identify a “trusted contact” for investment accounts. It also permits them to prevent the disbursement of funds from the account and to notify the contact if the broker suspects the client is an abuse victim." The article also mentions several states that have passed laws that require investment advisors to notify APS as well as state regulators if financial exploitation is suspected.
The article discusses some other efforts and provides a good picture of various efforts taking place both by legislation and industry efforts.
April 6, 2017 in Cognitive Impairment, Consumer Information, Crimes, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations, State Statutes/Regulations | Permalink | Comments (0)
Friday, March 17, 2017
I've blogged a couple of times recently about the fight against Alzheimer's disease. Here's a recent story about research efforts stymied by federal law. Big Alzheimer's research roadblock: Federal government was published by CNBC on March 9, 2017. "Promising new research conducted last year at the Salk Institute for Biological Studies has shown that marijuana extracts may hold a key to treating Alzheimer's disease. The next step: To conduct tests on mice and, if the results are promising, move on to human trials. But Salk Institute researchers have run into a major hurdle, and not a scientific one: the federal government. The Salk Institute is based in La Jolla, California — a state that legalized marijuana last November — but it is a federally funded research institute."
The story reminds us that although marijuana use may be legal in several states, it's still not ok at the federal level-it's still a controlled substance. And when a research institute like Salk gets federal dollars for research, there's a problem.
So does this mean a dead end for marijuana/Alzheimer's research? Not necessarily. There is a path, but it won't be a quick or guaranteed one. "In order to acquire marijuana for further studies, the lab must first apply to the Drug Enforcement Agency, which carries out the application process jointly with the U.S. Department of Health and Human Services. The Salk researchers sent in their application in December...." It takes several months for such a request to be approved. The article discusses the costs of Alzheimer's disease (which we have written about in prior posts)
The cost to the economy of caring for Alzheimer's and dementia patients was estimated to be about $236 billion in 2016. In 2015 a study funded by the National Institutes of Health estimated that the costs associated with late-stage dementia are greater than for any other disease.
During the last five years of a person with dementia's life, total health-care spending was more than a quarter of a million dollars per person ($287,038), about 57 percent greater than costs associated with death from other diseases, including cancer ($173,383) and heart disease ($175,136).
We all know how important it is to find an effective treatment (or even cure?) for Alzheimer's. For now, the folks at Salk have to wait to hear if they can move forward.
BTW, those astute readers will notice the url for the story includes the phrase "major buzz kill." To follow up, I'll close now with some my own pithy phrase, "dude, serious bummer". You insert your own pithy phrase here.....
Wednesday, March 15, 2017
Yesterday I blogged about the 2017 Alzheimer's Disease Facts & Figures. An article in Huffington Post focused on the impact on Medicare as the Boomers move into that age group where Alzheimer's risk increases. Rising Numbers Of Alzheimer’s Patients Could Bankrupt Medicare offers that
This year, for the first time, total costs related to caring for patients with Alzheimer’s will surpass a quarter of a trillion dollars, according to the Alzheimer’s Association annual report, released Wednesday.
With roughly 75 million boomers only beginning to reach the age of greatest risk for the disease, the U.S. may be disturbingly close to the tipping point for runaway Alzheimer’s-related health care costs. The 88-page report lays out some sobering statistics, including the possible bankruptcy of Medicare.
The article covers dual eligible, the need for funding and research, and some of the proposals from Congress. "Simply put, Alzheimer’s is a public health crisis. Yet due to the social stigma surrounding dementia, its full dimensions are still cloaked in shadow. Combating the disease is going to require that politicians and members of the public speak out and demand real solutions."
Tuesday, March 14, 2017
That is, the term “Alzheimer’s disease” is now used only in those instances that refer to the underlying disease and/or the entire continuum of the disease. The term “Alzheimer’s dementia” is used to describe those in the dementia stage of the continuum. Thus, in most instances where past editions of the report used “Alzheimer’s disease,” the current edition now uses “Alzheimer’s dementia.” The data examined are the same and are comparable across years — only the way of describing the affected population has changed. For example, 2016 Alzheimer’s Disease Facts and Figures reported that 5.4 million individuals in the United States had “Alzheimer’s disease.” The 2017 edition reports that 5.5 million individuals have “Alzheimer’s dementia.” These prevalence estimates are comparable: they both identify the number of individuals who are in the dementia stage of Alzheimer’s disease. The only thing that has changed is the term used to describe their condition.
The report contains a lot of good information that would help our students understand dementia and Alzheimer's. The section on prevalence is sobering. For example, "[a]n estimated 5.5 million Americans of all ages are living with Alzheimer’s dementia in 2017. This number includes an estimated 5.3 million people age 65 and older, and approximately 200,000 individuals under age 65 who have younger-onset Alzheimer’s, though there is greater uncertainty about the younger-onset estimate." (citations omitted). The report also explores the gender, ethnic and racial factors regarding prevalence of Alzheimer's. The report gives a breakdown by state. There is an amazing amount of critical information in this report. The report also includes a special report, Alzheimer's Disease: The Next Frontier.
I'm going to make it assigned reading to my students. Be sure to read this. It's important.
Friday, March 10, 2017
We all want a cure for Alzheimer's no question. If not a cure, then a way to prevent it. I blogged twice this week about Alzheimer's so I wanted to add one more story. Newsweek 's cover story for February 24, 2017 focused on prevention of Alzheimer's: The New Offensive on Alzheimer’s Disease: Stop it Before it Starts. The story opens with the news last year that an experimental drug failed to make much of an impact on those in the early stages of the disease. The story focuses on prevention:
This aggressive attempt to prevent Alzheimer’s rather than treating it is the most exciting new development in decades, as well as a radical departure for researchers and the pharmaceutical industry. Traditionally, drug companies have tested their therapies on patients who already have memory loss, trouble thinking and other signs of dementia. It’s been a losing tactic: More than 99 percent of all Alzheimer’s drugs have failed tests in the clinic, and the few that have made it to the market only ameliorate some symptoms. Not a single medicine has been shown to slow the relentless progression of the disease.
But with this new approach, even partial success—an appreciable slowing of brain degeneration—could have a big impact, says Dr. Reisa Sperling, a neurologist who directs the Center for Alzheimer’s Research and Treatment at Boston’s Brigham and Women’s Hospital. If a drug therapy can push back the onslaught of dementia by five or 10 years, she says, “many more people would die of ballroom dancing instead of in nursing homes.”
There are several ongoing clinical trials focusing on prevention, according to the article. There are also new tools to diagnosis Alzheimer's (where in the past, a brain autopsy was needed), We need to hope for a success, because otherwise, as the article points out, the numbers are very very bad:
The consequences of failure could be dire. Approximately 5.4 million Americans suffer from Alzheimer’s, and if no disease-delaying therapies are found soon, that number is expected to nearly triple by 2050, at which point the cost of treating and caring for all those people could top $2 trillion per year, after adjusting for inflation. That’s up from $236 billion today. O ne in every five Medicare dollars is now spent on people with Alzheimer's and other dementias. In 2050, it will be one in every three dollars. And those figures don’t even include the hundreds of billions more in lost wages for family members who take time away from their jobs to care for loved ones. It’s not a question of a day off now and again. People with Alzheimer’s require around-the-clock care—and more than one-third of all dementia caregivers develop clinical depression.
The article also discusses the costs and coverage of any medication that proves successful in preventing Alzheimer's. Stay tuned.
Tuesday, March 7, 2017
From the Washington Post, an especially moving account written by former White House Communications Director Jennifer Palmieri about her sister, who died at age 58 following some ten years with "early onset" Alzheimer's:
Every day, more Americans receive the devastating news that someone in their family has this affliction. For now, there is not a lot of hope for recovery. It can make you envious of cancer patients; their families get to have hope. Having come through this experience with my sister, I am afraid that I can’t offer these new Alzheimer’s families hope for a recovery. But I do hope that by relaying the story of my sister’s journey, I can offer them some peace.
My sister Dana was brilliant, beautiful, full of positive energy, a force of nature. She was not an easy person. She was driven and successful, and, as the disease progressed unbeknown to all of us, it became harder to connect with her. Ironically, that began to change once she got the diagnosis.
When she called each of us with the news, she already had it all figured out. We were all to understand that, really, she saw the diagnosis as a blessing. It was going to allow her to retire early. It would motivate our family to spend time together we would not have otherwise done. It would shorten her life, but she would make sure the days she had left were of the highest quality.
The thoughtful piece can help all of us as we and our family members tackle challenges. For more, read The Blessings Inside my Sister's Alzheimer's Disease.
Sunday, February 19, 2017
Kaiser Health News ran a story recently about the increase in Alzheimer's cases amongst Latinos. 'Tsunami’ Of Alzheimer’s Cases Among Latinos Raises Concerns Over Costs, Caregiving citing to a recent report explains
Across the United States, stories [of people with Alzheimer's] are becoming more common, particularly among Latinos — the fastest growing minority in the country.
With no cure in sight, the number of U.S. Latinos with Alzheimer’s is expected rise by more than eight times by 2060, to 3.5 million, according to a report by the USC Edward R. Roybal Institute on Aging and the Latinos Against Alzheimer’s network.
Advanced age is the leading risk factor for Alzheimer’s disease and the likelihood of developing Alzheimer’s doubles about every five years after age 65. As a group, Latinos are at least 50 percent more likely than whites to have Alzheimer’s, in part because they tend to live longer, the report notes.
Caregiving (which we have blogged about on several occasions) is of course an important issue for all of us, but in particular, this story explains, "[a]bout 1.8 million Latino families nationwide care for someone with Alzheimer’s and other types of dementia. And while the Roybal report shows that Latino families are less likely than whites to use formal care services, such as nursing home care, institutionalized care is becoming more common among these families." Although there are some in nursing homes, limited resources factor in to the family's ability to turn to outside help for the elder with Alzheimer's.
The story covers the economics of care, available community programs, the importance of public education, and resources for the family.
When seeking support, the best place to start is at a local community group or center — a church, a nonprofit, a United Way office, or the local Alzheimer’s Association chapter, for example, Mizis said. These groups will most likely refer caregivers to a county’s Agency on Aging or a state’s Department of Aging.
Friday, February 17, 2017
As we have discussed often on this Blog, one key issue in guardianships can be the right of access between third persons and the protected ward. Arizona has adopted a new rule expressly permitting individuals with "significant relationships" with a ward to petition the court for access if the appointed guardian is denying contact. A key section of the new law, adding Arizona Rev. Statutes Section 14-1536, effective as of January 1, 2017, provides:
"A person who has a significant relationship to the ward may petition the court for an order compelling the guardian to allow the person to have contact with the ward. The petition shall describe the nature of the relationship between the person and the ward and the type and frequency of contact being requested. The person has the burden of proving that the person has a significant relationship with the ward and that the requested contact is in the ward's best interest."
In deciding whether to grant access the court is obligated to consider the ward's physical and emotional well-being, and to consider factors such as the wishes of the ward "if the ward has sufficient mental capacity to make an intelligent choice," whether the requesting person has a criminal history or a history of domestic or elder abuse, or has abused drugs or alcohol. The new law also gives the ward the direct right to petition for contact with third persons.
"Significant relationship" is defined in the statute as meaning "the person either is related to the ward by blood or marriage or is a close friend of the ward as established by a history of pattern and practice."
The Arizona guardianship law was also amended to mandate that guardians notify "family members" when an adult ward is hospitalized for more than 3 days or passes away. Section 14-1537 provides notice shall be given to the ward's spouse, parents, adult siblings and adult children, as well as to "any person who has filed a demand for notice."
I have also run into the issue of access where the care for the incapacitated person is being provided by means of family member or third person acting through a "power of attorney." Sadly, in some states, the access issue triggers a full blown guardianship proceeding. Should a similar "significant relationship" test be used to provide a court petition-system outside of guardianships?
February 17, 2017 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, State Cases | Permalink | Comments (0)
Monday, February 6, 2017
Have you ever spent the night in a nursing home or dementia care center? How about for a week?
While on my sabbatical in Arizona I had the recent opportunity to spend several nights and many daytime hours in a care center. Quite simply, the experience deepened my respect and appreciation for the roles played by professional caregivers at all levels.
The facility in question is a nonprofit center, licensed for assisted living, and devoted exclusively to dementia care without restraints, the very definition of "mission driven" care. Set in a five acre campus, it is what I would call a "green house model" community (or more precisely, an Arizona Model Dementia Specific Assisted Living Project), with a maximum of twelve residents per cottage. It isn't a fancy place, but it is inviting, with a circular path between the four cottages that encourages people to sit under the trees, mingle and chat. Many residents are admitted on "private pay" status, but the center is also Medicaid certified.
Three shifts per day of CNAs (certified nursing assistants), usually at least two per cottage for each shift, provide the bulk of the personal care, cleaning, and meal service for the residents. The CNAs rotate shifts between the four cottages over the course of a single work week, sharing the workload of more challenging residents. There is also a small staff at the administrative level, including an executive director (who is working on her PhD thesis in her rare, spare time) and two LPNs, and there is regular input from both an MD and a very experienced Nurse Practitioner (who also has a PhD). A jack-of-all trades-building-maintenance-man, an up-beat program planner, plus two expert cooks round out the staff. I was on a nodding acquaintance with many of these people as a result of regular visits for close to three years, but my most recent ten days of "living in" gave me profound new appreciation.
The news media, for understandable reasons perhaps, tends to focus on tragedies and bad experiences in long-term care. Lawyers also tend to do the same, although for other reasons. At a recent legal conference, an experienced attorney who represents families in tort suits against nursing homes told me that in his experience, there are "no good nursing homes," only "less bad" ones.
Frankly, my experience, not just recently, but over 30+ years, is that there are very good care centers available. And the quality of living can be better than in the ol' homestead. It does take time to choose the right center for a loved one, and not every place will work for every person. I suspect the differences depend on how well any center identifies and supports its chosen mission of care. The attitude at the top affects the attitude of every employee.
To start at the executive director level, I learned this week that an awning that magically appeared one hot summer day to shade the favorite bench of one resident came from the director's own home. The attractive, sail-like canvas was adjusted "just so" between a building and a tree to provide maximum protection without making the often restless resident feel trapped.
Regular readers of the Elder Law Prof Blog may have guessed. That sun-worshiping resident was my father, a retired judge. He liked to hold court on that bench.
Another resident would often accompany the maintenance man on his daily rounds -- carrying a tool or pushing a cart. That probably slowed the maintenance man down. But I never heard a complaint. On "tough days" for that resident, when he wasn't tracking enough to safely accompany the maintenance man, that same employee would gently and kindly guide him by the shoulder back to his cottage.
One woman, who did not speak English, liked to dance. At the regular planned musical events, I would see even the shyest CNAs allow this woman to draw them onto the stage to join the entertainers with happy feet. My sister joined her in dancing too.
Another resident, who became one of my favorites, sadly had aphasia, making it hard for him to find words to express himself. Instead, he howled. I listened mornings and nights as those hard-working CNAs would correctly interpret his happy howls -- or his sad howls -- or his "I don't want a shower" howls, without losing patience.
This staff includes people born and raised in the U.S., including several from tribal lands. But there is always a shortage of CNAs. This particular staff also includes men and women who are immigrants from foreign lands: Mexico, several countries in Africa, the Middle East, eastern Europe, India, Indonesia, and the Philippines. Many of the caregivers, working 40 hours or more per week, were also caring for disabled relatives in Arizona, or were sending money "home" to support other family members in need. One caregiver, a permanent U.S. resident, is considering the tough question of whether to return to the country of birth in order to join a spouse currently detained and facing deportation for illegal entry. Their children, born in the U.S., would become strangers in that foreign land.
The workers at my father's assisted living center are part of a United Nations of Caregiving.
Wednesday, January 25, 2017
The winter issue of Columbia University's Magazine has an article on Your Beautiful Brain: Dispatches from the Frontiers of Neuroscience. I was particularly interested in the account of Nobel Prize-winning Professor Eric Kandel's 50+ years of research that began by looking at Aplysia -- a "blobby mollusk with protruding feelers that resemble rabbit ears" -- thus contributing to the mollusk's nickname, the "sea hare."
Clearly to Professor Kandel, the mollusks' brains were beautiful, not least because their comparatively large neural structures provided an accessible way to study more complex structures such as the human brain. Dr. Kandel, now 87, admits that "hunches" have played a role in his research.
From Columbia Magazine:
Today, as neuroscientists worldwide pursue remedies for Alzheimer’s and age-related memory loss, Kandel’s half century of findings are considered indispensable. Substantive therapies for Alzheimer’s in particular are “poised for success,” says Jessell, a colleague of Kandel’s for thirty-five years. “We’re on the cusp of making a difference.” But accompanying that claim is a caveat; the fledgling remedies are not panaceas. “We’re not necessarily talking about curing the disease,” he says. “But we are talking about slowing the symptomatic progression of the disease so significantly that lifestyles are improved in a dramatic way. If in ten years we have not made significant progress, if we are not slowing the progression of Alzheimer’s, then we have to look very seriously at ourselves and ask, ‘What went wrong?’”
Breakthroughs could happen sooner, however. Some of the Alzheimer’s medications available now “probably work,” says Kandel, except for one obstacle: “By the time patients see a physician, they’ve had the disease for ten years. They’ve lost so many nerve cells, there’s nothing you can do for them.” Possibly, with earlier detection, “those same drugs might be effective.” That’s not a certainty, insists Kandel, only a “hunch.”
Professor Kandel has also explored the biological differences between "ordinary" age-related memory loss and Alzheimer's Disease.
Years ago, Kandel had another hunch — that age-related memory loss was not just early-stage Alzheimer’s, as many neuroscientists believed, but an altogether separate disease. After all, not everyone gets Alzheimer’s, but “practically everyone,” says Kandel, loses some aspects of memory as they get older. And MRI images of patients with age-related memory loss, as demonstrated by CUMC neurology professor Scott Small ’92PS, have revealed defects in a brain region different from those of the early-stage Alzheimer’s patients.
Kandel also knew mice didn’t get Alzheimer’s. He wondered if they got age-related memory loss. If they did, that would be another sign the disorders were different. His lab soon demonstrated that mice, which typically have a two-year lifespan, do exhibit a significant decrease in memory at twelve months. With that revelation, Kandel and others deduced Alzheimer’s and age-related memory loss are distinct, unconnected diseases.
Then Kandel’s lab (again, with assistance from Small) discovered that RbAp48 — a protein abundant in mice and men — was a central chemical cog in regulating memory loss. A deficit of RbAp48 apparently accelerates the decline. Knocking out RbAp48, even in a young mouse brain, produces age-related memory loss. But restoring RbAp48 to an old mouse brain reverses it.
Now what may be the eureka moment — this from Gerard Karsenty, chairman of CUMC’s department of genetics and development: bones release a hormone called osteocalcin. And Kandel later found that osteocalcin, upon release, increases the level of RbAp48.
“So give osteocalcin to an old mouse, and boom! Age-related memory loss goes away.”
The same may prove true in humans. A pill or injectable could work, says Kandel: “Osteocalcin in a form people can take is something very doable and not very far away.” In less than a decade, age-related memory loss might be treatable. “This,” he says, “is the hope.”
For more on beautiful brains, read the full article on Columbia University's website.
Tuesday, January 24, 2017
Delirium and dementia are common causes of cognitive impairment in older populations. Although each may occur independently, delirium and dementia frequently coexist. Dementia is a leading risk factor for delirium, and there is an increased incidence of new dementia and cognitive decline after delirium. Delirium can accelerate the rate of cognitive decline, suggesting that an episode of delirium can result in a more rapid progression of dementia symptoms, leading to earlier functional disability, increased caregiver burden, and rising health care costs. As the population ages, there has been a rapid increase in the incidence and prevalence of delirium and dementia. Better understanding of the risk factors, outcomes, and mechanistic associations between these 2 conditions is therefore critical for developing successful prevention and treatment strategies for this increasing problem.
The conclusions and relevance from the article offers this:
CONCLUSIONS AND RELEVANCE Delirium in the presence of the pathologic processes of dementia is associated with accelerated cognitive decline beyond that expected for delirium or the pathologic process itself. These findings suggest that additional unmeasured pathologic processes specifically relate to delirium. Age-related cognitive decline has many contributors, and these findings at the population level support a role for delirium acting independently and multiplicatively to the pathologic processes of classic dementia.
A new one hour documentary, Alzheimer's: Every Minute Counts, is scheduled to begin airing nationally on PBS stations on Wednesday, January 25.
In part, the documentary will focus on research funding issues. Dr. Ruby Tanzi, a Harvard Medical School researcher who appears on the film, explained for NextAvenue's website:
We should be absolutely panicked at the government level. When the Medicare and Medicaid [treatment and care] bill for Alzheimer’s goes from one in five dollars to one in three dollars — that could happen over the next decade with baby boomers getting older — we could single-handedly collapse Medicare and Medicaid with Alzheimer’s disease.
Now, the government [research funding for Alzheimer's] has gone up to about a billion dollars. Which is great, it’s more money. It’s still not the billions of dollars that go to other age-related diseases. I’m glad that cancer and heart disease and AIDS get many billions of dollars, but Alzheimer’s has to get as much or more now given the epidemic and the urgency here with how many cases we’re going to have.
It’s going to crush us. Never mind the social burden on the families. I might add that two-thirds of patients are women. And most caregivers are women. What’s going to happen when so much of our female population is (struck) with this disease? So it’s a huge problem and if we don’t throw a ton of money at it now, it’ll be a disaster.
For more information on the documentary, including links to watch it on-line (free!), see PBS "Alzheimer's: Every Minute Counts." There is an important opportunity here for schools, including law schools, to host an airing of the documentary to promote discussion about strategies.