Friday, May 18, 2018

Doctors Discussing Gun Safety With Elder Patients

Kaiser Health News published a compilation of recent stories about gun safety and one caught my eye: the advantage of doctors discussing gun safety with elder patients. Doctors Should Be Discussing Gun Safety With Aging Patients, Researchers Say.

The reference to the story  from the LA TImes, As more older Americans struggle with dementia, what happens to their guns?seemed particularly on point and the KHN story published the opening from the LA Times article

The man had been a patient for decades, retired now from a career in which firearms were a part of the job. He was enjoying his days hunting, or at the shooting range with friends. But episodes of confusion had led to a suspicion of dementia, and the nights were the worst: At sundown, he became disoriented, anxious and a little paranoid, and had started sleeping with his loaded pistol under the pillow. One night, he pointed it at his wife as she returned from the bathroom. It wasn't clear whether he recognized her, but he was certainly confused — and she was terrified. Thankfully, the incident did not end in disaster.

Regardless of your position on the gun control debate, consider these statistics from the LA Times article

Roughly 1 in 3 adults over 65 in the United States is thought to own a gun. An additional 12% live in a household with someone who does.

As seniors turn 70, their odds of developing Alzheimer's disease in a given year jump from less than 1% (among those 65 to 69) to 2.5% (among those 70 to 74), and keep rising from there. By 2050, the number of older Americans with Alzheimer's is expected to reach 13.8 million.

The article discusses driver safety and draws corollaries to gun safety. The article highlights the lack of response to this issue at the state level:

No federal laws prohibit the purchase or possession of firearms by a person with dementia. Only two states, Hawaii and Texas, explicitly mention dementia or similar conditions in their firearms statutes.

In Hawaii, any person under treatment for "organic brain syndromes" is prohibited from owning a gun. Texas law makes individuals diagnosed with "chronic dementia" ineligible for a license to carry a handgun in public. But it does not limit such a person's right to purchase or possess firearms.

One expert quoted in the article describes this as not an issue of taking away someone's guns but instead a decision that focuses on the person's safety.

May 18, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Other, State Cases, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Tuesday, May 15, 2018

Pennsylvania Considering Changes to Guardianship Laws for 2018 Passage

Pennsylvania has several interesting bills pending that would make significant changes to the laws governing court-appointed guardians for incapacitated adults, and at least one of these could move forward this legislative session.  I've learned to expect late night action from the Pennsylvania legislature once it reconvenes in late May and before it adjourns in late June or early July.  The pending legislation includes:

  • Senate Bill 884 (Printer's No. 1147), with Senator Greenleaf as the lead sponsor, offered as a comprehensive reform package for adult guardianship laws, relying in large part on model legislation, and drafted before the most recent high profile news stories and editorials that involve allegations of improper appointment of a particular fee-paid guardian in a number of guardianships for incapacitated adults on the eastern side of the Commonwealth.  On April 16, 2018 this bill was referred to the Senate Appropriations Committee.  

I've seen recent drafts of proposed amendments to SB 884 that would require alleged incapacitated persons to be represented by a lawyer during the guardianship proceeding, require criminal background checks through the State Police (without creating automatic disqualifications if there is a history of convictions), and would also mandate "certification" for "professional guardians." Professional guardians are defined to include individuals or entities that are appointed to serve 3 or more incapacitated persons.  The responsibility for certification of the professional guardians would be assigned to the Pennsylvania Department of Human Services, although the proposed language would appear to permit the department to accept certification through an outside program such as that offered by the Center for Guardianship Certifications. 

  • House Bill 2247 (Printer's No. 3296), with Representative Gillen as the lead sponsor, and submitted in April 2018 following the high profile articles, would mandate criminal background checks for all current or prospective guardians and provides that courts "shall disqualify a guardian or prospective guardian convicted of an offense classified as a felony under the laws of this Commonwealth or a substantially similar offense under the laws of another jurisdiction."  

While the proposed amendment to S.B. 884 would require criminal background checks for potential guardians, unlike HB 2247, it stops short of banning appointment of individuals who have any particular criminal history. No doubt this decision reflects a 2003 ruling by the Pennsylvania Supreme Court in Nixon v. Commonwealth.  In that case, a per se ban on employment of individuals as long-term care workers if they were convicted of certain crimes was deemed unconstitutional.  Senate Bill 884, even if amended, would give greater discretion to the courts to consider the individual history and the nature of the offense than would HB 2247.

Continue reading

May 15, 2018 in Cognitive Impairment, Crimes, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, Housing, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (2)

Monday, May 14, 2018

Japan Mandates Cognitive Screening For Drivers Over Age 75

As reported by the New York Times, Japan is using mandated screening tools to remove older drivers who are identified as displaying signs of cognitive impairment:

Since 2009, all drivers 75 and older must submit to a test of their cognitive functioning when they renew their licenses, typically once every three years. Under a new traffic law that took effect in March 2017, those who score poorly are sent to a doctor for examination, and if they are found to have dementia, the police can revoke their licenses.

 

More than 33,000 drivers who took the cognitive test last year showed what the police deemed to be signs of cognitive impairment and were ordered to see a doctor. The police revoked just over 1,350 licenses after doctors diagnosed dementia.

For more, including photos of some of the screening tools, plus interesting demographic data about rural Japan, read Japan Moves to Ease Aging Drivers Out of Cars.  

 

 

May 14, 2018 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, International | Permalink | Comments (0)

Sunday, May 13, 2018

"Bullying in the Nursing Home" -- Getting Beyond the Headlines

News publication sites affiliated with USA Today and the Associated Press have been running a recent piece on "bullying" among older persons, often with a provocative headline such as "It's like 'Mean Girls,' but everyone is 80": How nursing homes deal with bullies.   The title undoubtedly catches many a reader's eye, simply because of the heightened discussions of bullying at a national level, including Melania Trump's recent announcement of her Be Best platform for younger persons.  The topic isn't actually all that new from a journalism perspective.  Paula Span wrote on "Mean Girls in Assisted Living" for the New York Times in 2011, and the same publication carried a granddaughter's Op Ed on "Mean Girls in the Retirement Home" in 2015.   

On a parallel track, and perhaps more disturbing, are reports of bullying among nurses, a profession normally associated with empathy and caring.  See e.g., "When 'Mean Girls' Wear Scrubs," a 2013 post on DiversityNursing Blog, tracking a several studies and a book.  

More important than the clever headlines, however, are the reports of affirmative efforts to counter the bullying, which at the older end of the spectrum of life, seems to focus on name-calling, gossip, and ostracising behavior, rather than physical intimidation.  From the most recent USA Today writer's article:  

After the cafeteria exiles and karaoke brouhahas, the 30th Street [Senior] Center [in San Francisco]  teamed up with a local nonprofit, the Institute on Aging, to develop an anti-bullying program. All staff members received 18 hours of training that included lessons on what constitutes bullying, causes of the problem and how to manage such conflicts. Seniors were then invited to similar classes, held in English and Spanish, teaching them to alert staff or intervene themselves if they witness bullying. Signs and even place mats around the center now declare it a “Bully Free Zone.”. . . 

 

Robin Bonifas, a social work professor at Arizona State University and author of the book “Bullying Among Older Adults: How to Recognize and Address an Unseen Epidemic,” said existing studies suggest about 1 in 5 seniors encounters bullying. She sees it as an outgrowth of frustrations characteristic in communal settings, as well a reflection of issues unique to getting older. Many elderly see their independence and sense of control disappear and, for some, becoming a bully can feel like regaining some of that lost power.

I think that last line rings true.  I've certainly seen older adults sudden strike a "meaner" demeanor as their freedom is limited by physical  health issues and as their frustrations increase.  But I also think it can be important to assess whether a "mean" trait -- or at least a "meaner" dynamic -- is a reflection of cognitive impairment, such as disinhibition associated with certain types of neurocognitive impairments.   

On an even more worrisome level, is there a danger of misinterpreting fear or irritation as "meanness," perhaps arising from compelled interactions in a congregated living situation?   In one instance, I've seen an older woman who had regularly chose to sit with the same group of 3 other individuals at meals for several weeks, suddenly reject one member of their informal club.  It took careful listening to realize the rejection was actually uneasiness bordering on fear -- on some level not completely rational -- but associated with that targeted individual's tendency to wander at night into others' rooms and thus to lead the "mean girl" to try to keep the other away from her around the clock.  Targeting the "bullying" behavior could be addressing the wrong problem in the latter case.  

Finally, I think there is a danger associated with the admittedly clever tendency to use the "Mean Girls" movie as the analogy for older bullying, thus implying this is only an issue (and problem) associated with women, not men.  As a later paragraph in the most recent article makes clear, bullying behavior among older adults is not "just" about women. But perhaps that is obvious from the larger national news?  

May 13, 2018 in Books, Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, Retirement | Permalink | Comments (0)

Sunday, May 6, 2018

Maryland Offers On-Line Orientation Video for Prospective Court-Appointed Guardians

As is true for many states, Maryland is increasing the education, support and supervision for guardians appointed by the Maryland courts.  In connection with this, beginning on January 1, 2018, prospective guardians must watch a video-based  "orientation program" before they are appointed guardian of a minor or disabled person.  The 9-minute video introduces the "roles, duties and responsibilities" of a guardian and explains mch of what to expect if appointed by the Maryland Courts.   Here is a link to the video.  

What I particularly like about this video is the message "You Are Not Alone as a Guardian," and the emphasis that Court-appointed guardians are subject to the ultimate authority of the Court.  I think that many courts are still struggling with their  own roles in this regard, but here the lines of responsibility are explained clearly.

The balance here is delicate, requiring careful thought about how to provide threshold information essential for a candidate to make an informed decision about whether to serve, but  without making the information so overwhelming that good candidates decline the role.  The Maryland courts caution that this particular orientation and the related training requirements do NOT apply to public guardians or guardianships that terminate parental rights. 

In my opinion, this type of video is a good first step.  But just a first step.  

May 6, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Legal Practice/Practice Management, Programs/CLEs, Property Management, State Cases, State Statutes/Regulations, Webinars | Permalink | Comments (0)

Tuesday, May 1, 2018

ABA Offers CLE on "Ethical Pitfalls Encountered by Lawyers with Diminished Capacity"

My thanks to Dickinson Law Professor Laurel Terry for pointing us to an upcoming seminar offered by the American Bar Association on "Competency and Cognitive Decline in the Legal Profession: Ethical Pitfalls Encountered by Lawyers with Diminished Capacity," on May 9, 2018, from 1 to 2:30 p.m. (ET). 

The promotional materials are a bit lean, but discussion topics are described as follows:

  • Understanding the effects of aging on the human brain
  • How to recognize some of the signs of diminished capacity
  • The practical and ethical considerations for intervention
  • Advice on how to facilitate discussion with the impaired person (or others who can help)
  • Resources and ways to locate assistance in your area
  • The importance of succession planning, and resources to help you develop or review your own succession plans

The speakers include Dr. Doris Gunderson, a psychiatrist in Colorado. 

Co-sponsors of the program including the ABA Center for Professional Responsibility, its Commission on Law and Aging, the Commission on Lawyer Assistance Programs, the Section for Civil Rights and Social Justice, the Senior Lawyers Division, and the Solo, Small Firm and General Practice Division.  

For more information on registering, see here.  

May 1, 2018 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Legal Practice/Practice Management, Programs/CLEs, Webinars | Permalink | Comments (0)

Monday, April 30, 2018

Health Affairs Blog Targets "Never-Ending Misuse of Antipsychotics in Nursing Homes"

I'm always interested in articles about the use -- misuse? -- of antipsychotic medications for older adults.  Therefore I was eager to read the recent post on the Health Affairs Blog by David Introcaso entitled The Never-Ending Misuse of Antipscyhotics in Nursing Homes. The article begins:

In response to a generic question about post-market drug surveillance posed during a February 2007 House Energy and Commerce Committee hearing, Dr. David Graham, then associate director of science and medicine in the Food and Drug Administration’s (FDA’s) Office of Surveillance and Epidemiology, stated: “I would pay careful attention to antipsychotic medications. … The problem with these drugs are that we know that they are being used extensively off label in nursing homes to sedate elderly patients with dementia … . It is known that the drugs don’t work in those settings. … But the fact is, is that it increases mortality perhaps by 100 percent. It doubles mortality. So I did a back-of-the-envelope calculation on this and you probably got 15,000 elderly people in nursing homes dying each year from the off-label use of antipsychotic medications for an indication that FDA knows the drug doesn’t work. This problem has been known to FDA for years and years and years.”

I've highlighted in bold the words that are the focus of my interest:  "It is known that the [antipsychotic] drugs don't work in those settings."  No citation to authority here - and it is the authority for this statement that I would like to see.  Is there a study of the use of antipsychotic drugs showing they "don't work" for dementia patients?  What does it mean "not" to work?  Is all "use" a "misuse" for patients who "only" have dementia?

I ask because I saw my father struggle at home for several years with dementia.  As the disease robbed him of the ability to understand where he was and why he couldn't remember things, he sometimes became aggressive.  He was still very strong.  His doctor tried various mild anti-anxiety drugs, but they seemed to interact with his blood pressure issues (and perhaps his other medications).  He would sometimes swing between aggressive behavior and losing consciousness.  Finally his doctor suggested a very small dose of an antipsychotic.  My mother was desperate for help at the time -- and thus, Dad started on the drug. This is an example of "off label" use.  I was worried, and said so, because I knew the associated concerns about increased mortality for those with dementia.  I looked for specific studies of risk versus benefit and frankly, all I could find were records showing the ratio of deaths for individuals with dementia who also were taking an antipsychotic drug.  Mere correlation is not necessarily evidence of causation. What I was looking for was a careful study of risk versus benefit.   

Over time I saw that the small dose did "work" for this one individual, my father.  He wasn't "knocked out."  He wasn't "docile."  He wasn't "asleep all the time" -- typical of the accusations that are often made about misuse of antipsychotics.  What we did see was that he was much less likely to strike out an arm or push someone hard when he was frustrated (and yes, he was still frustrated).   The small dose did not interfere with his blood pressure or the other medications he was taking.  Perhaps most importantly, he continued to live at home for many more months. Eventually it was appropriate to wean him off the antipsychotic altogether.  

One anecdotal account is not evidence.  But the fact that there reportedly continues to be "widespread"use of antipsychotic drugs by the elderly means there could be some very real need for  safe, effective alternatives. Behavioral health approaches are important, but those too can have limits in effectiveness.  I'd certainly like there to be "good" studies of the use of these drugs and any drug that might be able to help a person suffering from dementia live a less tormented life.  Not zoned out and not asleep all the time, but also not likely to harm themselves or those who on a daily basis are trying to help them live as normally as possible.    

April 30, 2018 in Cognitive Impairment, Consumer Information, Dementia/Alzheimer’s, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Science | Permalink | Comments (1)

Thursday, April 26, 2018

In Continuing Care or Life Plan Communities, Do Operators Face Liability for "Failing" to Transfer Residents to Higher Levels of Care?

Just as spring is finally seeming to arrive in the Mid-Atlantic region and I'm catching up on non-classroom projects, I realized I hadn't fully understood the potential legal issues in a tragic fact pattern from last winter, when an 85 year old women died after being trapped overnight outside her home near Philadelphia in March.  The legal issues are outlined in a suit filed against the CCRC where she was living in an "independent living" unit.  The lawsuit claims her "caregivers should have known" that she needed more care, pointing to the contractual language that permitted the facility to assess and transfer her to a more  supervised setting as her care needs increased.  From the Philadelphia Inquirer on February 9, 2018 :    

Her son, Blake Rowe, a drug company scientist, has filed suit against Shannondell at Valley Forge in Audubon and its security company, Universal Protection Service LLC, claiming that they should have done more to protect his mother. She had been allowed to stay in an independent-living apartment after Shannondell knew she had a tendency to become confused and wander aimlessly, the suit says.

 

“I put my trust in them. They said they would do an assessment they never did,” said Rowe, who got the “horrible” news that his mother was in the hospital as his plane landed in Florida for his honeymoon.  As for the security company, he said, “If they were doing their rounds, someone would not be at a door for five hours freezing to death.”

Ironically, I often hear from family members protesting the compelled transition of a resident to a higher level of care, as the family members may disagree more help is needed, or feel the help can be provided adequately "in" the independent living unit.  The Inquirer article summarizes the dilemma for operators and families:  

The Hinds case also illustrates a trend in senior housing — at all levels of care, including independent living, residents are older and have more health problems than in the past — with safety implications that may surprise families. Most seniors want to be as independent as they can for as long as they can.  Families shopping for senior apartments may want to look beyond the quality of the food or beauty of the grounds and ask what will happen when a loved one declines:  Were your buildings and security designed with dementia in mind?  Whose job is it — the family’s or the facility’s — to start the conversation when a resident needs more help?

For more on the "Hinds" case, see His Elderly Mother Wandered Out Into the Cold and Died.  Whose Fault Was It? 

 

April 26, 2018 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, Housing, State Cases, State Statutes/Regulations | Permalink | Comments (0)

How a Dementia Diagnosis Depletes Life Savings

The San Jose paper, the Mercury News ran an important story about the impact of dementia on life savings. This isn't something new to elder law attorneys, but it's an important recognition of how Medicare covers health care based on a diagnosis.  How dementia can drain a family’s life savings  offers this heading " Medicare offers no help for the high costs of dementia caregiving."  We know that Medicare has certain requirements for coverage. As the article explains it

”Medicare is a lifeline for seniors and the disabled, paying for “medically necessary” costs such as hospitalization, surgery, chemotherapy, transplants, medications, pacemakers and other interventions... A dementia diagnosis demands none of that. What it does require, however, is around-the-clock “custodial care,” such as help with eating and dressing, and constant supervision. That’s not covered by Medicare. And it’s extraordinarily expensive, according to a report released last month by the Alzheimer’s Association...Families’ out-of-pocket costs for a patient with dementia are 80 percent higher than the cost for someone with heart disease or cancer, according to a 2015 study in the Annals of Internal Medicine.

How much can families expect to spend caring for those with dementia?  The story says 60 BILLION (yes that's not a typo-60 BILLION) based on a report from the Alzheimer's Association.  That doesn't include those who have early onset Alzheimer's.

The options are few for those with this diagnosis.  Long Term Care Insurance, paying privately, Medicaid quite possibly, but really not Medicare unless there is a hospitalization. Forget home care or memory care being covered by Medicare, the article notes.

This is not a new issue but it's certainly becoming a bigger issue with the significant number of Boomers. Read the article. It's important!

 

April 26, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Federal Statutes/Regulations, Health Care/Long Term Care | Permalink | Comments (0)

Monday, April 23, 2018

You Are Only as Old As You Feel!

You've heard the phrases such as "60 is the new 40." Now we learn there may be some truth to the thought that you feel younger than your chronological age.The Washington Post recently published this article, Cliches about only being as old as you feel are starting to have scientific backing.

The article focuses on research that indicates many folks who are older feel good about themselves and about the negative messages about aging that affect us all.  The article references "[o]ne study ... [that] found that as people get older, they consistently say they feel younger — much younger — than their actual age. Another study examining the attitudes of the offspring of centenarians concluded that the centenarians’ children — if they, too, were healthy and long-lived — have a strong sense of purpose and meaning to their lives, compared with the general population. Finally, there is evidence that positive attitudes about aging may reduce the risk of dementia, among the most dreaded consequences of aging."  Yet, we start being bombarded with negative messages about aging at a very young age. One expert noted  that kids even age 3 or 4 already have absorbed "the age stereotypes of their culture,” which it seems come from "many sources, ranging from stories to social media. Individuals of all ages can benefit from bolstering their positive images of aging.” Another expert quoted in the article explains that “[n]egative views about aging are communicated to us early in life, through media, books and movies, and what our friends and family tell us... [and that such] attitudes are present and pervasive already in childhood, so naturally it’s hard to enact meaningful change to these attitudes....”

Several studies are referenced in the article. The studies bear out the idea that folks who are older feel younger than their chronological ages, but as far as younger people's perceptions, they consider old to be a lower number than those who are old would offer. For example, one researcher offered that "teenagers and young adults equated turning 50 with hitting old age."

And we've all heard the saying about attitude is everything. It turns out those with positive views of aging help with reducing stress and decreasing chances of dementia. One research summarizes her findings: She "evaluated 4,765 older people — average age, 72 — who were free of dementia at the start of the study and followed them for four years. The participants answered a series of questions about their beliefs about aging [and the researchers] found [that] those who expressed more-positive age beliefs at baseline were less likely to develop dementia . . . than those who expressed more-negative age beliefs...."

So remember, the class is half-full and aging is not a bad thing!

April 23, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Other, Science, Statistics | Permalink | Comments (0)

Thursday, April 19, 2018

Sentate Special Committee on Aging Hearing on Guardianships

Yesterday, the Senate Special Committee on Aging held a hearing on guardians exploiting individuals under guardianship. The hearing, "Abuse of Power: Exploitation of Older Americans by Guardians and Others They Trust.”  offered 4 witnesses, including elder law prof, and reporter of the new Uniform Guardianship, Conservatorship & Other Protective Arrangements Act, Associate Dean Nina Kohn. The committee chair and ranking member opened the hearing with their individual statements.  Their statements, along with the witnesses' testimonies, are downloadable as pdfs. There is also a video of the hearing, available here.

April 19, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Health Care/Long Term Care, Property Management, State Cases, State Statutes/Regulations | Permalink

Wednesday, April 18, 2018

New Issue Brief from National Center on Law & Elder Rights

The National Center on Law & Elder Rights has released an issue brief, Drafting Advance Planning Documents to Reduce the Risk of Abuse or Exploitation.  The issue brief offers 4 key lessons:

  1. Extra care in the creation of advance care planning documents can reduce the risk of abuse and exploitation.
    2. Requiring accountability, additional checks and balances, and limited authority are drafting tools lawyers can utilize to limit risk of abuse.
    3. Attorneys should advise clients to be extra diligent when selecting the agent(s) named in advance planning documents.
    4. Authorizing revocation by third parties can help to limit the damage done by named agents who start to abuse or exploit the client. 

I was intrigued by #4-the idea of naming a third party who could step in.  The section, Five Safeguards to Consider Adding to a Financial POA discusses that among others.  Here's how the issue brief explains the third party revocation provision: "Grant a power to revoke the agent’s authority to a trusted third person. This is a serious power to give any third person, so it requires an exceptional level of trust and reliability in the third person. But, if the agent’s actions prove seriously out of line, this can be a last resort. Some powers of attorney also authorize law enforcement or adult protective services to revoke the authority of the agent if they believe abuse or exploitation is taking place." Sample language is also included for each of the 5 Safeguards.

The brief discusses selection of agents and drafting health care directives in addition to drafting POAs. Practice tips are included as well as case examples. The issue brief is available here.

To learn more about the corresponding webcast click here.  To download the PowerPoint for the webcast, click here.

April 18, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Other, Programs/CLEs, Property Management, State Statutes/Regulations, Webinars | Permalink | Comments (0)

Wednesday, April 11, 2018

2018 Alzheimer's Facts and Figures

The Alzheimer's Association has released their annual facts and figures report. 2018 Alzheimer's Disease Facts & Figures also includes a special report on the benefits (personal and financial) of early diagnosis.  Here are some highlights of topics covered in the report:

  • Brain changes that occur with Alzheimer’s disease …
  • Revised guidelines for diagnosing Alzheimer’s disease …
  • Number of Americans with Alzheimer’s dementia nationally … and for each state …
  • Proportion of women and men with Alzheimer’s and other dementias …
  • Lifetime risk for developing Alzheimer’s dementia …
  • Number of deaths due to Alzheimer’s disease nationally … and for each state … and death rates by age …
  • Number of family caregivers, hours of care provided, and economic value of unpaid care nationally and for each state …
  • The impact of caregiving on caregivers …
  • National cost of care for individuals with Alzheimer’s or other dementias, including costs paid by  Medicare and Medicaid and costs paid out of pocket …
  • Medicare payments for people with dementia compared with people without dementia
  • Benefits of earlier detection of Alzheimer's disease …
  • Cost savings of diagnosing during the earlier mild cognitive impairment stage rather than the dementia stage …

There is a lot of helpful information and statistics in the report. The chart showing the numbers of those with Alzheimer's in 2018 compared to the projections for 2025 is very useful. (Just fyi, my state is expected to have a 33.3% increase). Consider this from page 21 of the report:

“[B]etween 2018 and 2025 every state across the country is expected to experience an increase of at least 13 percent in the number of people with Alzheimer’s. These projected increases in the number of people with Alzheimer’s are due to projected increases in the population age 65 and older in these states. The West and Southeast are expected to experience the largest percentage increases in people with Alzheimer’s between 2018 and 2025. These increases will have a marked impact on states’ health care systems, as well as the Medicaid program, which covers the costs of long-term care and support for some older residents with dementia.”

Read this!

 

April 11, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Other, Science, Statistics | Permalink | Comments (0)

Sunday, April 8, 2018

As Individuals with Developmental Disabilities Live Longer, They May Outlive Caregiver Parents

During Dickinson Law's recent program on Dementia Diagnosis and the Law, one of our panelists, Elder Law practitioner Sally Schoffstall raised an issue planning professionals are seeing more often, families who are concerned about the long-range needs of children with developmental disabilities. I know that over the years I have often had law students whose interest in disability and estate planning law began with a brother or sister with special needs, and they are thinking about their own future roles in helping the family plan. 

The good news is that better early health care often means an extended life for disabled children, but that very fact raises the probabilities on living longer than the people who have been primary caregivers, especially their parents. As we heard from medical professionals at our conference, individuals with Down Syndrome, for example, are now less likely to succumb to physical impairments such as developmental  heart problems, but still face a significant risk of early onset of dementias, with an estimated 30 percent of those in their 50s already experiencing symptoms similar to Alzheimer's Disease.  

On May 21-22, a St. Louis-based nonprofit organization, Association on Aging with Developmental Disabilities (AADD) will hold its 28th annual conference.  The conference draws an audience of professionals from a wide range, including social workers, nurses and other service providers.  As with most people, individuals with disabilities want to "age in place," and that takes extra planning to manage financial assets.  Pamela Merkle, executive director for AADD explains:

"Sessions will focus on giving them the tools they need to successfully support people with developmental disabilities who are aging,” says Merkle. 

 

She explains that many of the issues faced by older persons with developmental disabilities mirror those of aging individuals in general, such as isolation, depression and how to handle retirement. “Like most people, they want to ‘age in place,’ not spend their golden years in a nursing home. Given that living within the community is more cost-effective, it’s important to both the seniors and our communities that there be more public programs to support that choice,” she continues. . . . 

 

For individuals who are 50 or older, AADD offers retirement services. While some of the participants have held community-based jobs, others spent decades in sheltered workshops. As with many members of the general population, they often tend to define themselves through the jobs they held for so many years. “So we focus on identity: ‘I’m a volunteer” or “I’m active in my church,’” explains Merkle. “If you don’t have something in place to fill the void after retirement and to maintain the skills you’ve developed, you’ll retire to your couch. You won’t be an active part of the community, and will most likely spend your “golden years” alone.”

For more, see this commentary from the Special Needs Alliance, and look for related links.  My thanks to Sally for providing links to this conference information! 

April 8, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Health Care/Long Term Care, Housing, Legal Practice/Practice Management, Programs/CLEs | Permalink | Comments (0)

Tuesday, April 3, 2018

More on Dementia Advance Directives

Recently we wrote about a dementia advance directive and now, Kaiser Health News has a story about an ‘Aggressive’ New Advance Directive Would Let Dementia Patients Refuse Food. where "a New York end-of-life agency has approved a new document that lets people stipulate in advance that they don’t want food or water if they develop severe dementia. ...The directive, finalized [in March] by the board for End Of Life Choices New York, aims to provide patients a way to hasten death in late-stage dementia, if they choose.."  The article explains that although dementia is a terminal condition, the medicaid aid-in-dying laws don't apply to someone with it. So instead, "[t]he document offers two options: one that requests “comfort feeding” — providing oral food and water if a patient appears to enjoy or allows it during the final stages of the disease — and one that would halt all assisted eating and drinking, even if a patient seems willing to accept it."

There was a significant amount of press coverage about whether an advance directive covers hand feeding as a result of a case out west where a patient with an advance directive was hand fed over her husband's objections.  Typically the directives are silent about the provision of food and fluids by hand. Here, "[t]he New York directive, in contrast, offers option A, which allows refusal of all oral assisted feeding. Option B permits comfort-focused feeding.... [with] both options ... invoked only when a patient is diagnosed with moderate or severe dementia, defined as Stages 6 or 7 of a widely used test known as the Functional Assessment Staging Tool (FAST). At those stages, patients would be unable to feed themselves or make health care decisions."  This document is different than the one  we reported on in our earlier blog post. As the article explains, "[t]he new form goes further than a similar dementia directive introduced last year by another group that supports aid-in-dying, End of Life Washington. That document says that a person with dementia who accepts food or drink should receive oral nourishment until he or she is unwilling or unable to do so... [while the]  New York document says, 'My instructions are that I do NOT want to be fed by hand even if I appear to cooperate in being fed by opening my mouth.'"

Experts interviewed for the article expressed concerns about whether such instructions would be honored.

Stay tuned.

 

April 3, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Dementia/Alzheimer’s, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (1)

Thursday, March 29, 2018

Penn State's Dickinson Law Hosts Pennsylvania Judges for Program on "Dementia Diagnosis and the Law"

Dickinson Law's CJE Program on Dementia Diagnosis and the LawOn Thursday, March 29, 2018 Penn State's Dickinson Law hosted a continuing judicial education program for the Pennsylvania Judiciary, with live attendance in Carlisle by more than 30 judges and with even more judges around the state participating via a live stream.  The program was "Dementia Diagnosis and the Law," organized into three parts:

Part 1:  Medical Science and Dementia

Panel Discussion and Audience Q & A

Part 2:  Legal Implications of a Diagnosis of Dementia

  • Keynote Presentation:  Clinical, Legal and Judicial Judgments of Capacity in Persons with Dementia
  • Why “Guardianship Oversight” is a Hot National (and State) Topic
    • Professor Katherine C. Pearson, Dickinson Law, Pennsylvania State University

Panel Discussion and Audience Q & A

Part 3:  Adjudication Exercises, facilitated by Professor Tiffany Jeffers, Dickinson Law, with Dickinson Law students in role plays on issues about capacity to contract, limited guardians, the roles of guardians ad litem and the potential for attorneys or judges to become affected by a neurocognitive disorder.

  • Panel Discussion and Audience Q & A

Panel Members included:

As the law school's organizer for the event, I know I learned a lot from this dynamic group of seasoned experts who spoke on the challenging legal, medical, and judicial issues that can arise from cognitive impairments associated with aging. The judges in our audiences were fully engaged, offering great comments, questions and experiences.

My special thanks to each and every one of the speakers, facilitators, judges, lawyers and students who made the program so informative.  It was fun to work with the Administrative Office of the Pennsylvania Courts on this project and we look forward to additional opportunities to collaborate in the future.  Once I catch up a little on my day job (and maybe on some missed sleep), I'll post again with some additional reactions and thoughts from this program.  

March 29, 2018 in Cognitive Impairment, Crimes, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Health Care/Long Term Care, Housing, Legal Practice/Practice Management, Property Management, Science | Permalink | Comments (1)

New Mexico, Where New Guardianship Laws Will Take Effect July 1, 2018, Struggles With Reporting Systems

Earlier this week, The Albuquerque Journal reported on continued problems with accountability for court-appointed guardians within New Mexico. Colleen Heild writes:

What’s become of Elizabeth Hamel? Hamel is among dozens of people placed under a legal guardianship or conservator in southern New Mexico over the past 20 years whose welfare is unknown – at least according to state district court records. . . . Nothing in the online court docket sheet indicates that Hamel’s case has been closed. But since being appointed, Advocate Services of Las Cruces hasn’t filed any annual reports about Hamel’s well-being or finances, the docket sheet shows.

 

There’s no indication as to whether she is dead or alive, or if the  guardianship/conservatorship has been revoked. . . . 

 

As New Mexico prepares for a new law, effective July 1, to help its ailing guardianship system, the state’s district courts still don’t have a uniform way to ensure guardian compliance with reporting laws that have been on the books at least since 1989.

 

State Sen. Jerry Ortiz y Pino, D-Albuquerque, said last week that he was disappointed that annual reports haven’t been filed in some cases.

 

“And I’m not surprised the courts wouldn’t know,” said Ortiz y Pino, a longtime advocate for reform. “That’s what we ran into over and over again, the lack of any kind of system to make it possible to log them (annual reports) in, let alone read them, let alone send somebody out to verify whether or not what they’re reporting is the truth. Those are the kind of things we shouldn’t be missing. Somebody should be at least saying, ‘Hey, you never did file a report.’ ”

For more, read Missing Reports Plague Guardianship System (3/25/18). 

March 29, 2018 in Cognitive Impairment, Crimes, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Property Management, State Cases, State Statutes/Regulations | Permalink | Comments (1)

Monday, March 26, 2018

Maryland Courts Tackle the Challenge on Guardianship Reform

Maryland is among the several states putting serious energy into modernizing and reforming rules governing guardianships, with major new rules that took effect on January 1, 2018.  In Bifocal, the journal of the ABA Commission on Law and Aging, the Honorable Karen Murphy Jensen, who chaired a multidisciplinary workgroup tackling the state reforms, describes the process during an interview.  She notes the work ahead for many: 

Judge Jensen: These are big changes and courts, attorneys, and guardians need time to navigate them. Maryland’s circuit courts are not uniform and the changes will affect each court differently. Guardianship attorneys need to familiarize themselves with the new requirements and procedural changes. The orientation and training requirements add a step to the process that may overwhelm some prospective guardians and each individual court will have to respond to that reality. 

 

Along the way, the Workgroup consulted with and got feedback from judges, court staff, private attorneys, public agencies, and other service providers outside of the Workgroup. It was clear that the Workgroup would need to provide ongoing technical assistance and develop resources to help everyone navigate these changes once in effect. While sensitive to the impact on family guardians, we believe it is important for guardians to understand what is expected of them and know what tools are available upfront, and for courts to screen out those unable to take on the responsibility.

For more, read: Maryland Judicial Workgroup Spearheads Guardianship Reforms, Vol. 39, Issue 3, Bifocal. 

March 26, 2018 in Cognitive Impairment, 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, March 22, 2018

The Perils of Serving as a Financial Caregiver

At the invitation of the editor for the ABA Commission on Law and Aging's journal, Bifocal, I wrote a recent article on The Perils of Serving as a Financial Caregiver. I described a fundamental challenge:

What are the family dynamics? Will appointment of one individual create a trap whereby an overlooked or disgruntled offspring, sibling or spouse demands an accounting?  Even successful defense against a weak claim will involve costs to the financial caregivers and to the principal's estate.  Family dynamics can also change over time, especially as feelings of resentment, guilt or denial begin to color relationships. Consider whether greater transparency within the family at all phases of the relationship involving handling of financial matters will deter later problems.

Using an article in the The New York Times today, my words of caution appear mildly framed, compared to the reality of what appears to be one family's deeply embedded dynamic following the death of the parents, pitting two sons against a daughter and her husband over the family fortune in Arkansas.  

“I want this finished, over and done,” Sanders McKee [one son] said in his deposition. “I am tired of wasting my life. She needs to stop wasting her own. And I’m tired of this. I’m absolutely exhausted with it.”

 

But that was in August 2014, and the legal battle continues, costing all sides money and time. The Noels [daughter and son-in-law] estimated that they have spent $1 million on legal fees in the case, and they’re not resting. 

 

Aside from the cost, the case also demonstrates the strain being a trustee can put on family members.

For the full cautionary tale, read Are Millions Missing? Some Relatives Want to Know.  Others Don't, by Paul Sullivan.

Hat tip to my Dickinson Law colleague, Professor Laurel Terry, for the pointer to this interesting New York Times  piece.

March 22, 2018 in Current Affairs, Dementia/Alzheimer’s, Estates and Trusts, Ethical Issues, Legal Practice/Practice Management, Property Management, State Cases | Permalink | Comments (0)

Wednesday, March 14, 2018

Dementia-Friendly City in Heart of Silicon Valley

Somehow I never thought I'd right that phrase. Yet, Palo Alto is taking steps to become a dementia-friendly city! Palo Alto looks to become a 'dementia-friendly city' explains that

Palo Alto is among a growing number of communities around the world that have begun to look at how government, businesses and residents can work together to provide better resources — like training for first responders, community support networks and policies that better aid employees who are also caregivers — for the expanding population of aging adults who are being diagnosed with dementia.

Palo Alton has a little more than 30,000 residents now who have dementia (including Alzheimer's) and it is estimated that that number will exceed 50,000 by 2030. "As part of its broader push for an "age-friendly Silicon Valley," Santa Clara County last year joined Dementia Friends, a global movement begun by the Alzheimer's Society in the United Kingdom to change the way people think about dementia."

A public hearing on this is scheduled for late March.  Thanks to my colleague and dear friend Mark Bauer for alerting me to this article.

 

March 14, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Other | Permalink | Comments (0)