Saturday, January 31, 2015
My colleague and great friend, Professor Laurel Terry, shared Paul Sullivan's Wealth Matters column from the New York Times, that uses the new movie Still Alice as a reminder of the importance of family conversation:
"For anyone who has ever watched a family member disappear into Alzheimer’s, Ms. Moore’s performance is gripping, particularly as her tricks to stall her decline inevitably fail and the later stages of the disease consume her. Yet the movie is also a great vessel to explore many of the financial issues that families need to address when someone is diagnosed with Alzheimer’s or any other disease that causes cognitive impairment."
The column continues with thoughts from financial professionals, who sometimes observe the early signs of a long-time client's decline:
"Thomas Mingone, managing partner at Capital Management Group of New York, said he had clients whose mental slide had been apparent to the advisers, accountants and lawyers in the room but not to the client. Since advisers are bound by a fiduciary duty to protect their clients’ privacy, Mr. Mingone said he can’t simply call up their children to let them know. With a client who seems to be slipping but lives alone and sees family members infrequently, Mr. Mingone said he suggests a family meeting, which allows him to connect with his client’s children. Other times, he said, just asking clients how they are doing brings the problem out.
'Sometimes when you bring this up with clients, it’s a relief to them,' he said."
For additional realities, including the problem of end-of-life decision-making and care choices, read "In Alzheimer's Cases, Financial Ruin and Abuse Are Always Lurking."
Sunday, January 25, 2015
NPR's All Things Considered began a series on January 24th that follows Greg O'Brien's journey with early-onset Alzheimer's, beginning with his diagnosis at age 59. There is lots of important stuff here, including the need for family dialogue and understanding. One dialogue is between the father and son, about why it was important for the son to serve as his dad's agent under a Power of Attorney.
Here's an excerpt from O'Brien's powerful account:
"How do you tell your kids that you got Alzheimer's? It sucks.
I had planned this family meeting, so all the kids were home and we're going to go out to dinner. I knew I had to talk beforehand.So I'm in the bathroom, you know I felt a little bit like Luca Brasi in The Godfather, practicing my speech. 'On the day of your daughter's wedding....'
I could hear, 'Daddy,where are you?' So I came out and I went over the fact that their great-grandfather, my grandfather, had died of Alzheimer's and my mother, which they knew. And now it's come for me...."
Thursday, January 22, 2015
If you have a loved one with dementia, particularly if you have watched him or her lose the power to communicate with words, perhaps you have wondered, what are they thinking? What are they hearing when you talk with them? Are they happy? Sad? Is confusion the dominant, or only, feeling?
You sometimes get hints of how they feel, including recognition they may feel profoundly trapped. I knew one man who, when he could not find the words, would shake his head and howl. I knew one woman who, when she was younger, used to have clever catch-phrases. By the time she was in her 80s, she had lost the ability to say a favorite phrase but she would say two words -- "Head up"-- over and over. She wanted you to help her complete the phrase. Her caregivers did not know that she had given hundreds of children horseback riding lessons, and misunderstood her words as a warning, perhaps motivated by paranoia. But, as one of her former students, when I heard her say "Head up" during my visit, I responded -- almost automatically -- with "Heels down." It is an equestrian's mantra for balanced riding. And she smiled as if we had just completed reciting the Gettysburg Address together.
With that background, I was captivated by a recent public radio broadcast, now available on an Invisibilia podcast, about the "Locked-In Man." Following an illness and a coma as a child, Martin Pistorius began to "awaken" during his teens, but for more than 10 additional years he was unable to talk, or even to signal to people caring for him -- or abusing him -- that he was "aware" of what was happening.
Imagine being trapped in front of reruns of "Barney" (television's purple dinosaur) day after day after day, for year after year. I know a senior care facility that seems to have the "King and I" playing on a television around the clock. Could Yul Brynner's singing be just as much torture as Barney's for someone who is unable to say "not again?"
Wednesday, January 21, 2015
A new acronym, VSED, is emerging in discussions of end-of-life decision making. It refers to Voluntarily Stopping Eating and Drinking. However, what happens when such a plan is combined with increasing dementia?
As addressed in Paula Span's thoughtful piece for The New York Times' "The New Old Age," it may not be possible to ensure such a plan will be honored, at least not under the existing law of most states. Consider the following example:
"Like many such documents, [Mr. Medalie's Advance Directive] declares that if he is terminally ill, he declines cardiopulmonary resuscitation, a ventilator and a feeding tube. But Mr. Medalie’s directive also specifies something more unusual: If he develops Alzheimer’s disease or another form of dementia, he refuses 'ordinary means of nutrition and hydration.' A retired lawyer with a proclivity for precision, he has listed 10 triggering conditions, including 'I cannot recognize my loved ones' and 'I cannot articulate coherent thoughts and sentences.'
If any three such disabilities persist for several weeks, he wants his health care proxy — his wife, Beth Lowd — to ensure that nobody tries to keep him alive by spoon-feeding or offering him liquids. VSED, short for 'voluntarily stopping eating and drinking,' is not unheard-of as an end-of-life strategy, typically used by older adults who hope to hasten their decline from terminal conditions. But now ethicists, lawyers and older adults themselves have begun a quiet debate about whether people who develop dementia can use VSED to end their lives by including such instructions in an advance directive...."
For more, continue reading "Complexities of Choosing End Game for Dementia." Thanks to Elder Law Attorney Morris Klein for sharing this good article.
Friday, January 9, 2015
Criminal behavior in older adults, including theft, traffic violations, sexual advances, trespassing, and public urination, may be a sign of dementia, researchers say. There is a subgroup of people, especially older adults who are first-time offenders, who may have a degenerative brain disease underlying their criminal behavior, said Dr. Georges Naasan of the Memory and Aging Center and Department of Neurology at the University of California, San Francisco. He and his coauthors reviewed the medical records of 2,397 patients diagnosed with Alzheimer’s disease or other types of dementia between 1999 and 2012. They scanned patient notes for entries about criminal behavior using keywords like ‘arrest,’ ‘DUI,’ ‘shoplift’ and ‘violence’ and uncovered 204 patients, or 8.5 percent, who qualified. Their behaviors were more often an early sign of frontotemporal dementia (bvFTD) or primary progressive aphasia (PPA), a type of language-deteriorating dementia, than of Alzheimer’s disease.
Read more at Reuters.
Thursday, January 8, 2015
The Denver Post ran an article on Sunday January 4, 2015 about early detection of Alzheimer's. Alzheimer's disease researchers pursue early detection reports about the work researchers have done that has led the, according to one scientist to "the brink of understanding." Researchers at the U. of Colorado in Boulder have been working diligently, with a new drug trial and a proposal for "a federally funded research center..." The article quotes an expert from the Alzheimer's Association about how early detection is so important:
"There's broad recognition now that the brain changes that lead to Alzheimer's disease occur long before there are any symptoms," [Dr. Keith] Fargo said. "By the time changes in cognitive abilities are evident, you have lost a lot of brain cells, and much of what is going to happen with Alzheimer's disease has already happened."
Dr. Fargo goes on to note that it may take 10-20 years before it's actually found and by then, it's too late to undo the damage. Thus the race to find a way to diagnose Alzheimer's before the symptoms show up. The article discusses the work researchers are doing to figure out ways to detect the disease early on. These range from using PET scans to blood tests to "genetic profiling." The trial starting at U. of Colorado involves the "protein released in the brain of people with rheumatoid arthritis. They don't develop the disease." Another interesting area of research involves the sense of smell: those individuals who aren't good at "identifying smells are at high risk of Alzheimer's... [since the] cranial nerve that affects the olfactory sense is one of the first areas involved in brain degeneration."
This is one race we want the researchers to win-soon.
Tuesday, December 30, 2014
Researchers at the Polisher Institute at the Abramson Center for Jewish Life have published the results of a controlled study on use of non-drug approaches to behavioral assistance for individuals with dementia.
The study, titled "A Randomized Controlled Trial for an Individualized Positive Psychosocial Intervention for the Affective and Behavioral Symptoms of Dementia in Nursing Home Residents," is published in the January issue of the Journal of Gerontology (Series B: Psychological Sciences), which is accessible via subscription. From the abstract:
Objectives. This randomized controlled study tested the effectiveness of individualized activities, led by certified nursing assistants (CNAs), to increase positive and reduce negative affect and behavior among nursing home residents with dementia.
Method. Nursing home residents with mild to advanced dementia (N = 180) were randomly assigned to usual care (UC, n = 93) or 1 of 2 experimental conditions. Residents in the attention control group (AC, N = 43) participated in standardized one-to-one activities with their CNAs. Individualized Positive Psychosocial Intervention (IPPI) participants (n = 44) received a CNA-led activity matched to their interests and ability. Outcomes were residents’ positive and negative affect and verbal and nonverbal behavior.
Results. The IPPI and AC groups experienced similar benefits—more pleasure, alertness, engagement, positive touch, and positive verbal behavior—compared with UC. The AC group displayed more anger, uncooperativeness, and very negative verbal behavior than UC or IPPI.
Discussion. This study demonstrates the value of individualized activities for nursing home residents with dementia. In a stringent test, residents were happier and less angry during a customized intervention compared with a standardized intervention. Even brief individualized CNA-led activities bring pleasure to nursing home residents and constitute an effective strategy to enhance positive affect and engagement in persons with dementia.
It would be interesting to know more about what appears to be a potentially significant difference not only between the "standardized" interventions and the "individualized" approaches, but also between the different types of individualized approaches.
Tuesday, December 23, 2014
A timely reminder during this holiday season, and as we plan our New Year's Resolutions. Exercise regularly! From the Washington Post, reports of research from the University of Wisconsin School of Medicine and Public Health:
Evidence continues to accumulate that physical activity can help hold off the changes in the brain associated with Alzheimer's Disease, and perhaps the devastating symptoms of the disease itself. The latest information comes from researchers at the University of Wisconsin School of Medicine and Public Health, who looked at 317 late-middle aged adults and determined that those who exercised five times a week or more had fewer of the age-related changes in the brain that are associated with the disease, and did better on cognitive tests.
Age remains the single greatest risk factor for Alzheimer's, greater even than having the gene found in many people with the disease, the study confirmed. But "what we have shown here is that physical activity diminishes the deleterious influence of age," said Ozioma Okonkwo, an assistant professor of medicine at the school who led the study.
Saturday, December 20, 2014
Here is a link to a podcast for a Smart Talk program from WITF Public Radio, where Zygmont Pines, Esq., Court Administrator for the Commonwealth of Pennsylvania and I were invited to talk about quite a few "hot" topics from Pennsylvania Supreme Court's Elder Law Task Force. The Task Force released its big Report and Recommendations last month.
The topics strike me as quite universal, not Pennsylvania specific. If you make it to the last few minutes (or skip ahead), there is an especially poignant moment with a family caregiver, who tells a real life story that will strike a chord with many.
December 20, 2014 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Health Care/Long Term Care | Permalink | Comments (1) | TrackBack (0)
Friday, December 19, 2014
New York Times Op-Ed Columnist Frank Bruni recalls his own reluctance to confront the realities of Alzheimer's, offering a touching account of his own grandmother many years ago, whose condition caused him to turn away. But as he also points out in his column, "Confronting an Ugly Killer," "the world is different now. Much of the unwarranted shame surrounding Alzheimer's has lifted. People are examining it with new candor and empathy."
As evidence for his observation, he points to the latest movie, Still Alice, with Oscar buzz already starting for Julianne Moore's performance.
Wednesday, December 17, 2014
Researchers at Stanford Unviersity School of Medicine have released their latest study of brain cell degeneration in mice, suggesting the potential importance of blocking the influence of certain molecular processes associated with inflamation and Alzheimer's disease:
“'Microglia are the brain’s beat cops,' said Katrin Andreasson, MD, professor of neurology and neurological sciences and the study’s senior author. 'Our experiments show that keeping them on the right track counters memory loss and preserves healthy brain physiology.'”
Here is Stanford's new release, summarizing the study published this month in the Journal of Clinical Investigation. Hat tip to Dickinson Law's Professor Laurel Terry for sharing this news.
Tuesday, December 16, 2014
Mark Friedman, an elder law and special needs attorney from New Jersey, recently wrote to comment on the important series offered by National Public Radio on use and misuse of certain medications in long-term care settings. Here is what Mark said:
"NPR ran a story on 'chemical restraints,' - nursing homes using anti-psychotic drugs to make unruly residents more pliable. According to the article, the residents are usually Alzheimer’s or dementia patients, and anti-psychotics can make the residents easier for staff to manage. But the drugs can be dangerous, increasing a resident’s risk of falls and exacerbating health problems. At high doses, anti-psychotics can also sap away emotions and personality and put the resident into a 'stupor.'
Administering drugs in this manner, any drugs, including anti-psychotics, without medical need and for the convenience of staff, is contrary to federal regulations. Unfortunately, it may also be widespread.
The NPR story includes a tool drawn from CMS data that shows the rate of residents on anti-psychotics at nursing homes across the country. You can look up the facility in which your loved one resides.
The news coverage shows that this issue is getting increased attention, and that’s a good thing. I think that as Americans age and more people have spouses and parents in nursing homes, the use of anti-psychotics as chemical restraints will have to diminish or end. People won’t stand for their loved ones being drugged into a stupor."
Thanks, Mark, for making sure we included this topic and the latest links for more coverage and your additional commentary. Along the same lines, I listened to an interesting follow-up conversation on AirTalk, a Los Angeles public radio affiliate's program, discussing "How California is Doing in the National Fight to Curb Over-Medication of Nursing Home Patients." That program, now available as a 23-minute podcast, included an articulate medical professional, Dr. Karl Steinberg, who described how he sees medication practices changing in long-term care, including better use of behavior health techniques, rather than medication, to help residents.
December 16, 2014 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Science | Permalink | Comments (0) | TrackBack (0)
Saturday, December 13, 2014
AirTalk, a program aired daily by Public Radio affilliate KPCC in Southern California, hosted a discussion about the issues identified in news articles about the Iowa criminal case, where a husband faces "statutory rape" charges for having sexual relations with his wife after she was diagnosed with advanced dementia and began residing in a nursing home.
Here's the link to a podcast of the December 12, 2014 segment.
December 13, 2014 in Cognitive Impairment, Crimes, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0) | TrackBack (0)
Thursday, December 11, 2014
In August, I reported on criminal charges filed that month in Iowa, charging a husband with sexual abuse of his wife who was living in a nursing home.
As a result of that post, I was invited by a reporter, who was working on an extended analysis of the case, to review certain information and records emerging from the case. Much of my own research is closely focused on issues both of capacity and protection.
The more one reads about the Iowa case, the sadder it seems. Even though at first it seemed the husband, a state legislator, might be expected to have sophisticated legal knowledge of the implications of what it might mean for his wife to be diagnosed with dementia, it became pretty clear -- at least to me, reading from afar -- that the husband is a fairly simple guy: A farmer, high school education, part-time legislator who liked pig roasts and parades, and someone who cared deeply for his second wife, trying as hard as possible to see her as "just a little" impaired.
I suspect that for many of us who have experiences with a loved one with dementia, there is a phase of denial, not just about the fact of dementia, but about the level of dementia. I remember one instance where a client always had her husband sign their joint tax returns, because even with Alzheimer's, he was "able" to sign his name clearly.
Reading the statute used to charge the Iowa husband also gave me pause. Iowa Code Section 709 was the basis of the sexual abuse charges. Sexual abuse in the third degree under Section 709.4 could be charged where a sex act "is done by force or against the will of the other person." That provision did not seem to apply. Charges could also be brought where the act is between persons who are not cohabiting as husband and wife, "if any of the following" is true: "The other person is suffering from a mental defect or incapacity which precludes giving consent."
Section 709.1A of the Act defines "incapacitation" to include "mentally incapacitated" or "physically incapacitated" and neither quite seemed to apply. Under Iowa law, "mentally incapacitated" means that a person is "temporarily incapable of apprising or controlling the person's own conduct due to the influence of a narcotic, anesthetic, or intoxicating substance." And "physically incapacitated" means that a person has a bodily impairment or handicap that substantially limits the person's ability to resist or flee."
So, how was the husband charged? He was charged under Section 709.4 (2)(a) on the grounds that his wife, with whom he was not "cohabiting," suffered from a "mental defect" that precluded giving consent.
So that makes the "elder law" issue fairly stark: Has his wife's diagnosis of dementia, especially advanced dementia, prevented her from giving legally effective "consent?"
Friday, December 5, 2014
I've written often in our Blog, including here and here, about our growing awareness and national concern about the issue of financial exploitation of older persons. In brainstorming a bit with another attorney about a thorny case -- and trying to decide where a parent/child relationship went wrong -- I was reminded of the work of Professor Karen Hooker, PhD at Oregon State University's School of Social and Behavioral Sciences. A major focus of Professor Hooker's work is the influence of "personality" in aging across the lifespan. She has examined spousal caregivers for persons with dementia, looking to see how the individual's view of self and the relationship affects "success," including successful caregiving. Another part of her work has examined closely the issue of "ambivalence" in family relationships.
For example, in Dr. Hooker's research, her team used qualitative study methods to examine older parent/adult child relationships. One of the major themes emerging when parents (each aged 67+) talked about their children was awareness that their children were "busy," and thus there were often ambivalent feelings of need and dissatisfaction about the parent's interactions with their children. The study revealed feelings both of resentment and pride about their busiest children.
That has led me to think that "ambivalence" may also be a component of voluntary "principal and agent" relationships, where the adult children are asked by the parent to serve as an agent under a power of attorney, for example. But as the adult child exercises more control over financial matters, might that parent also begin to have second thoughts, thoughts that are not acted on until "too late." The children believe they had authority to "pay themselves" for their roles in handling matters for their aging parent; the parent initially agrees, or at least does not object, and only later, after the money is gone, asserts some "agreement" about the financial matters, arguing there was an "understanding," even if never express at the outset? There is room for more research here, yes?
Thursday, December 4, 2014
Via the Toronto Star:
Ever since she was a teenager, Ashley Kwong knew she wanted to open her own seniors’ home. Now, almost two decades later, her dream is finally becoming a reality. Kwong is launching Memory & Company next spring — and she’s touting the Markham facility as Canada’s first private Alzheimer’s program. Kwong says Memory & Company will have a spalike feel, with well-lit rooms, secured outdoor spaces and programming such as music therapy, gardening and yoga. There will be a five-to-one staffing ratio and an on-site nurse. Costs, which range from $100 per day for basic care to $150 for those with more advanced Alzheimer’s, are on a par with many long-term care facilities and retirement homes. While more expensive than many day programs, Memory & Company will offer a different type of experience, catered specifically to the needs of people with Alzheimer’s and dementia, Kwong says. Clients will be free to roam the health club’s 11,000-square-foot space with a circular design to decrease their dementia-related agitation while wandering through the rooms. Clients will also have access to a salon, gym, dance studio and hydrotherapy spa, alongside outside services like massages and physiotherapy. “We’re also using iPad technology to provide more individualized care, instead of planning the whole program for the month and not caring what people are in the building,” Kwong says. “It’s a different approach than the assembly style of day programs right now.”
Read more at the Toronto Star.
Monday, December 1, 2014
There are so many things vying for our attention, and many of us may find ourselves easily distracted (say for example, by shiny objects). I like to use the example of Dug the talking dog from the fabulous movie, Up. (Going off on a tangent, consider using this movie in your classes, it's great) But I digress...or perhaps I was distracted....
Kurzweil AI ran an article on November 26th, 2014 reporting on a study on how to train an "aging brain" to ignore distractions. Disruptive sounds help aging brain ignore distractions reports on a new study, the results of which are published in the journal, Neuron. The study, Adaptive Training Diminishes Distractibility in Aging across Species is available with subscription or by purchase here. The abstract explains the study:
Aging is associated with deficits in the ability to ignore distractions, which has not yet been remediated by any neurotherapeutic approach. Here, in parallel auditory experiments with older rats and humans, we evaluated a targeted cognitive training approach that adaptively manipulated distractor challenge. Training resulted in enhanced discrimination abilities in the setting of irrelevant information in both species that was driven by selectively diminished distraction-related errors. Neural responses to distractors in auditory cortex were selectively reduced in both species, mimicking the behavioral effects. Sensory receptive fields in trained rats exhibited improved spectral and spatial selectivity. Frontal theta measures of top-down engagement with distractors were selectively restrained in trained humans. Finally, training gains generalized to group and individual level benefits in aspects of working memory and sustained attention. Thus, we demonstrate converging cross-species evidence for training-induced selective plasticity of distractor processing at multiple neural scales, benefitting distractor suppression and cognitive control.
Back to the Kurzweil AI article about the study. The Kurzweil story notes that "[d]istractibility (the inability to sustain focus on a goal due to attention to irrelevant stimuli) can have a negative effect on basic daily activities, and is a hallmark of the aging mind." The article notes the applicability of the research, including applications for individuals with autism or for "individuals struggling with a variety of distractions." The Kurzweil article notes the two-fold results of the study, "highlighting the therapeutic potential of this type of brain training to improve our ability to focus with age, it also shows that even in the aged adult, the brain is responsive to learning-based approaches that can improve cognition."
I was pondering the results of this study vis a vis individuals suspected of having diminished capacity. I was wondering whether there is application of the training to those individuals who may have difficulty with some ADLS if due to distractability. Would this be a temporary or long term solution and an alternative to guardianship for some?
Tuesday, November 25, 2014
Ramping up into Thanksgiving celebration, thinking about the things for which we are thankful---how about adding caregivers to that list? Huffintong Post Third Metric ran a three-part series earlier this month on Unsung Heroes: The Face of American Caregiving. The Unsung Heroes Who Give Up Everything To Take Care Of A Sick Partner, the first installment in the series, focused on eleven extraordinary caregivers providing care to spouses/partners. The second, The Unsung Heroes Who Give Up Everything To Take Care Of A Sick Parent covers 10 family members providing care for their parents., 9 of whom are over the age of 50. The final installment, The Unsung Heroes Who Give Up Everything To Take Care Of Multiple Loved Ones covers ten amazing individuals who have provided care for multiple generations.
Knowing the statistics on caregiving, a number of us will be called upon to provide the care. These folks will inspire you. Happy Thanksgiving.
Tuesday, November 18, 2014
In Gunnarson v. Transamerica Life Insurance Company, a federal district court in the state of Washington issued a November 6, 2014 order remanding the case to state court on diversity grounds, rejecting the company's argument that joinder of an individual sales agent as a defendant in the case was merely a step to prevent the out-of-state corporate entity from removing the case to federal court.
In rejecting the fraudulent joinder argument, the federal district court outlined several pending factual and legal issues between the parties arising from the dispute over long-term care insurance (LTCI) coverage. The issues include:
- whether the defendant agent's relationship with the insurance company, Bankers United (Transamerica's predecessor), was "disclosed" to the purchasers, relevant because under Washington Law, joint and several liability applies to agents of undisclosed principals;
- whether written promotional materials on LTCI provided by Bankers United barred a claim for misrepresentation in light of alleged oral misrepresentations by agent at the time of sale regarding dementia care; and
- whether a claim of misrepresentation, for a policy of LTCI sold 18 years ago, is barred by the statute of limitations, or whether there is an issue of fact about whether and when the purchaser knew or should have discovered that benefits would be paid only for "nursing home" facility care.
In Washington, as in many states, state law changed to expressly require LTCI insurers to cover non-nursing home based care; however, the statutory change apprently occured after the effective date of the policy in question.
The federal court order linked above resulted in remand to the state court for further proceedings under Washington law. (Allegations, of course, are not the equivalent of proof.)
Thursday, November 13, 2014
With the most recent news about actor Robin Williams as possibly having Lewy Body Dementia, readers might find free webinar materials from Morningside Ministries useful, at their website mm.learn.org. Look for the "In the News" link -- the materials strike me as objective and thoughtful.