Wednesday, December 11, 2013
The Royal College of Physicians of Edinbrugh is hosting a symposium on "Ethics and Care for Older People Approaching End of Life: Symptoms, Choices and Dilemmas" on April 3 in Scotland. While many of the sessions focus on medical treatment, as one might expect given the setting, the program takes an interdisciplinary approach, with sessions on:
- Pain mangement in older people
- Palliation of symptoms in advanced dementia
- Nutrition in advanced frailty
- Escalating care vs. ceiling of intervention: two sides of the same coin?
- Advanced care planning in the community: choice or chimera?
The keynote address is "Meeting the Challenge of Delivering Quality Care for Older People in the Last Days of Life."
The website explains how to identify or establish connections for live streaming of the program to venues overseas.
Monday, December 9, 2013
National Council on Aging Urges Public Support for This Week's Vote on "Qualified Individual" Medicare Funding
From the National Council of Aging (NCOA) a call for action, urging people to write their federal legislators:
This week, House and Senate Committees are scheduled to vote on a bill to permanently fix the longstanding problems with Medicare physician payments. The bad news is that the Medicare Qualified Individual (QI) Program may not get the fix it needs—leaving nearly half a million low-income people with Medicare facing new, unaffordable costs or reduced access to their doctors.
The QI program pays Medicare Part B premiums for beneficiaries with incomes of about $14,000-$15,500, most of whom already must spend over a quarter of their meager income on health care.
If the bills fail to make the QI program permanent, low-income seniors could be forced to drop the Part B benefit and lose access to their doctors, or pay over $1,200 in new, additional premiums.
This means that a senior with just a $14,000 income would only have $9,000 left for all their other living expenses.
The NCOA offers an easy form to use in emailing your Congressional representatives to urge them to vote to make the QI program permanent to protect seniors' economic security and access to physicians.
As readers of this blog will be aware from previous posts, Pennsylvania courts are willing to enforce the Commonwealth's filial support law. The law, at 23 Pa. C.S.A. Section 4603, makes spouses, parents or adult children potentially liable to "care for and maintain or financially assist" each other where the care-needing family member is "indigent." Pennsylvania's law has been interpreted as giving nursing homes or other third-party caregivers standing to sue.
The suits can cross state lines, usually because the target defendant is an out-of-state son or daughter of a nursing home resident in Pennsylvania, thus creating potentially interesting questions of personal jurisdiction. But the latest suit I've seen is an interesting twist on that fact pattern.
In Eades v. Kennedy, P.C. Law Offices, filed in United States District Court for the Western District of New York, a New York husband and daughter are the plaintiffs, suing a Pennsylvania law firm that attempted to collect a nursing home debt "by means of at least one item of correspondence and at least one telephone call." The plaintiffs in the New York suit are also apparently defendants in a Pennsylvania lawsuit filed by the nursing home. At issue is a bill for $8,000. The nursing home in question, located in Corry, Pennsylvania, is just a few miles south of the New York state line.
In the New York suit, Eades asserts that the collection attempts violated the Fair Debt Collection Practices Act (FDCPA) and further that the law firm's allegations of their liability under Pennsylvania's filial support law is "preempted" by federal Medicare/Medicaid law, under a provision of the Nursing Home Reform Act (NHRA) that bars a nursing home from requiring "a third party guarantee of payment to the facility as a condition of admission."
The New York federal district court dismisses the suit, concluding that there is no "jurisdiction," apparently both on subject matter jurisdiction and personal jurisdiction grounds. But then the ruling gets more interesting. The court proceeds to address the substantive claims by the family members, and seems to conclude that a cause of action under the FDCPA is not triggered by a "support" claim, including a filial support claim. Further, the court suggests there is no preemption under federal law for the following reasons:
"The NHRA holds that nursing homes may not require an individual's relatives to assume personal liability for the individual's care as a condition of admission or continued residence in the facility. The Pennsylvania indigent statute cannot be said to cover the same territory: it merely holds that where a resident is or becomes indigent, a nursing home may seek payment or reimbursement for the resident's care from their spouse, children or parents. It does not bypass the NHRA by permitting or excusing the assumption of personal liability by a relative for a nursing home resident's care as a consideration of admission or continued residence -- the sole evil that the NHRA ... appears to have been intended to prevent."
On December 3, 2013, the New York court dismissed the father/daughter's amended complaint for failure to "state a claim." The case is Eades v. Kennedy, P.C. Law Offices, No. 12-CV-66801, 2013 WL 6241272 (W.D. N.Y. 2013).
Sunday, December 8, 2013
Recently I was invited to give the keynote address for an annual meeting of MaCCRA, the Maryland Continuing Care Residents Association, held at Vantage House in Columbia, Maryland. As always happens, I learned a great deal from the opportunity to meet with individuals who care deeply about their communities and want to see them continue to succeed. Maryland is home to some 37 Continuing Care Retirement Communities (CCRCs), with close to 20,000 residents.
MaCCRA has a long and especially interesting history of advocating for appropriate protections for current and future residents of Continuing Care Retirement Communities. Most recently, between 2008 and 2012, MaCCRA supported a series of legislative efforts, including some that were ignored or soundly defeated, but culminating in passage of Senate Bill 485 and House Bill 556 in 2012 that amended of Maryland's CCRC oversight laws (Md. Code. Ann. Hum. Serv. Sections 104-1 et seq.). For example, the amendments require:
- greater disclosure of how entrance fees will be used or held, including a requirement of express disclosure about whether fees will or can be used for purposes unrelated to the community;
- greater disclosure of ownership interests in the community;
- disclosure of annual budgets (not just financial statements);
- increase of operating reserves from 15% of net operating expenses to 25%, with a ten-year phase-in; and
- certain restrictions on encumbrances of operating reserves
Such successes have required perseverance, with MaCCRA playing an important role in educating residents across the state as well as legislators. Indeed, MaCCRA understands that grass root movements alone may not be enough, and the organization has worked for twenty years with an experienced lobbyist, thus helping to assure institutional memory while working in small and large ways to urge greater accountability by providers.
One of the questions I frequently am asked during interactions with CCRC resident groups around the country is whether the most appropriate administrative unit of state government to provide oversight is the department of insurance. My response is that the name on the door is not as important as the state's commitment to hiring knowledgeable individuals with finance-specific training and who are not captives to the industry, regulators who are willing to take a balanced approach to oversight. The current operation of the unit of Maryland's Department of Aging charged with oversight of CCRCs strikes me as providing a good example of that commitment.
MaCCRA is a chapter of the National Continuing Care Residents Association (NaCCRA); during my visit to Maryland I learned that a MaCCRA member was an early leader in forming NaCCRA.
Friday, December 6, 2013
A recent issue of the ABA's Dispute Resolution Magazine (Fall 2013) included an article on "Elder Mediation: Coming of Age," authored by two mediation trainers, that tracks the growth of mediation for elder disputes in a variety of settings. The authors conclude: "Skilled, dedicated professionals can help parties find paths to agreements on some of the toughest and most emotional issues that families face."
Included within the article was a listing of elder dispute resolution resources:
- Alaska Court Program
- ABA Commission on Law and Aging
- Bet Tzedek
- Center for Civic Mediation, Elder Care Mediation Program
- Center for Dispute Resolution, Missouri State University
- Center for Social Gerontology
- Circuit Court of Cook County Elder Law & Miscellaneous Remedies Division
- Elder Decisions
- Elder Mediation Program of Mosaica Center for Consensual Conflict Rsolution
- Good Shepherd Elder Dispute Services Program
- LGBT Elder Care Intitiative
- Multi-Door Division of the Superior Court of the District of Columbia
- Northern Virginia Mediation Service
- Wise and Healthy Aging
Hat tip to my colleague at Penn State Dickinson, Professor Nancy Welsh, for sharing a copy of the issue. Nancy is co-chair for the editorial board for Dispute Resolution Magazine.
Thursday, December 5, 2013
Calling it a "matter of first impression," an intermediate appellate court in Pennsylvania has ruled that a woman's renunciation of her interest in a dissolved marital support trust was a transfer "for less than fair consideration," thus triggering ineligibility when she entered a nursing home and applied for Medicaid.
As reported in Schell v. Pa. Department of Public Welfare, decided December 4, 2013 by the Pennsylvania Commonwealth Court, a testamentary trust was dissolved in 2009, leaving approximately $300,000 to be distributed to the settlor's widow. The widow formally renounced her interest in the distribution, permitting the sum to be divided equally between the couple's two children, one of whom was disabled. Two years later, in 2011, the widow entered a nursing home and applied for Medical Assistance.
While DPW accepted the widow's "hardship" argument regarding the half distributed to the disabled daughter, the Court upheld DPW's challenge to the distribution of the other half to the son. The Court rejected the widow's argument that the penalty period could not apply to a trust created more than five years before her nursing home admission, on the ground that the key event was termination of the trust within the Medicaid lookback window:
"Once the trust was dissolved, Petitioner became entitled to any remaining income and principal therein. This income and principal was available for Petitioner to use for her support, but she made an affirmative decision not to receive the same, without any good cause explanation for so doing. . . . Upon Petitioner’s renunciation, the trustee distributed half of the remaining income and principal from the trust, $151,231.76, to her son. Petitioner received nothing in return, and, thus, the [Bureau of Hearings and Appeals] properly concluded that this transfer was for less than fair market value, thereby resulting in the imposition of a penalty period of 582 days."
Wednesday, December 4, 2013
In my travels, I often talk with families struggling to care for aging loved ones in the parents' home. One frequent topic is how challenging it can be, especially in certain parts of the country, to find reliable home care workers, especially if no adult child lives close enough to supervise.
Recently, one family described to me an additional complication, what to do when the best home care workers insist on being paid in cash, under the table. Here's the setting:
"When my father began to need more care than my mother could provide on her own, and more than I could provide by driving up for long weekends, we tried local agencies. We had almost constant problems with untrained workers and frequent turnover. I decided to try to hire someone directly, realizing that part of the problem was the low rates paid to the employees by the agencies, usually less than half of what we were paying the agency. In some instances the individual was making just over minimum wage, and often the agency refused to pay overtime, because our state law exempts home care workers from certain threshold Labor rules. When I started looking, I discovered that the agencies were advertising on Craig's List too, and I realized the agencies were finding it hard to get reliable workers. We were competing for the same workers.
Finally, I talked to a local Veterans office, who suggested that sometimes informal teams form, almost as spin-offs from an agency, and will work directly for the family. The team members are used to working together, and would cooperate with each other to meet our growing needs for around-the-clock care. They charge less than the agencies, but their take-home pay is higher.
I finally found this kind of local team, two mature women who would work on a shift system, coordinating with each other to provide reliable care. But there was one big problem. They refuse to sign a contract, work for an agency, or have any record of their care, and they won't work for our family if we insisted on withholding for taxes or Social Security. After weeks of problems with agencies, we were desperate, and they knew it. Even though Dad qualifies for VA aide & attendance, we cannot get reimbursed without proper records. The irony is these two woman are providing the best care we've had to date for my parents, and they are reliable. But they are insisting on cash. Frankly, they have us over a barrel, at least for the current emergency."
As depicted on the U.S. Department of Labor website, state laws vary on whether in-home care workers are covered by minimum wage and overtimes rules. The catch-22 is that in many instances, paying higher rates would make home-care unaffordable for families. However, low pay and no benefits are often analyzed, if not addressed, as issues of fairness for the worker, rather than the employer.
Unreported income is, of course, a long-standing issue for taxing authorities, usually discussed in the context of hiring a nanny, house-cleaner, or gardener. Is under-the-table pay for home care workers a trend in your area of the country? Feel free to send us links to emerging legal research on this topic.
Tuesday, December 3, 2013
First Court Challenge FiledTo State Statute Restricting Assistance to Consumers Seeking ACA Coverage
In Ontario, laws governing Powers of Attorney impose special rules in the context of personal care. The Advocacy Centre for the Elderly (ACE) in Toronto, has published a series of white papers, collected on their website, discussing the restrictions on uses of Powers of Attorney for Personal Care (POAPCs), including a paper on the potential for misuse of authority. There is an interesting legal limitation on the use of POAPCs for admission to a care facility, requiring oversight for the decision if the principal disagrees with the agent's decision, with the potential for two steps to the process. ACE Staff Attorney Rita Chrolavicius writes:
"The Health Care Consent Act deals with treatment, admission to long-term care homes and and personal assistance services received in long-term care homes. . . . A POAPC does not come into effect until there has been a finding by a health care practitioner or evaluator that a particular individual is incapable with respect to the treatment or admission decision. If the individual disagrees with the finding of incapability, a hearing can be held before the Consent and Capacity Board. This provides some protection to the individual."
I can certainly see a reason for this restriction; however, at the same time, it strikes me that many persons with dementia or other conditions triggering the need for third-party care might resist the decision. How often is it necessary to go before the Board? I look forward to learning more about the practicality of the hearing process before Ontario's Consent and Capacity Board.
USA Today continues reporting on criminal misuse of resident funds held in accounts at nursing homes, pointing to the lack of clear laws requiring faculities to conduct audits or other oversight systems for resident accounts:
"Federal law provides the regulatory framework for the nation's 16,000 nursing homes, which have to meet an array of standards to participate in Medicare and Medicaid. Federal rules do not require audits for resident trust fund accounts, and most states take the same approach.
The U.S. Centers for Medicare and Medicaid Services, the federal agency responsible for nursing home regulation, is considering whether additional oversight is needed to address theft and mismanagement of residents' funds.
'We are aware of this situation and are reviewing the (inspection) procedures used to detect these kinds of problems,' agency spokesman Aaron Albright said when asked about USA TODAY's findings. 'CMS takes safeguarding nursing home patients very seriously.'"
Monday, December 2, 2013
At the heart of comparative research is the opportunity to rethink your own system. I was reminded of this point last week when meeting Claire Keatinge, the Commissioner for Older People in Northern Ireland (COPNI). Commissioner Keatinge is -- in a word -- dynamic, and it is impossible not to be impressed with her dedication to meeting the needs of older persons in her country. She is a leader, both actually and symbolically, for a hard-working team tackling a number of issues in ageing policy.
It is clear to me that "independence" is at the core of the role for the COPNI. What do I mean by independence? The COPNI is funded with public dollars, but the job includes making an independent evaluation of the needs and interests of the demographic, and then reporting and advocating for appropriate response by the government or other sectors. By comparison, I wonder whether state officers or offices charged with policy and laws in the U.S.are more likely to be serving a governmental agenda, and trying to sell that agenda to voters. This strikes me as a potentially important, if subtle, difference in systems.
A small example of the importance of independence: One of the COPNI's several goals is to identify and improve "uptake" of benefits available to older persons in the country. In Northern Ireland, and elsewhere in the U.K., there are official statistics on the dollars (whoops, I mean pounds) left on the table by individuals who fail to seek available public benefits or services. In N.I., there is a known gap. By comparison, I would be surprised to learn that we keep similar statistics on either the state or federal level in the U.S., much less have a policy of trying to reduce any gap.
Claire Keatinge also stressed that an individual assessment of need for health care, social care and security, should be exactly that, and not simply an assessment of what services are available. Helping individuals or their family members access services in the public, private and voluntary sectors is part of the COPNI plan of action, but, it strikes me that the emphasis on evidence-based policies may result in development of new services or better funding for existing programs.
Thursday, November 28, 2013
Devolution, the process in the United Kingdom by which Scotland, Wales and Northern Ireland are enacting domestic laws and policies separate from the laws of England, has opened important opportunities to consider the needs of older persons.
Over the Thanksgiving weekend, I'm in Northern Ireland, working with great colleagues at Queen's University Belfast, on two projects commissioned by the Commissioner of Older People Northern Ireland (COPNI). One team is working on elder abuse and the other project focuses on social care, with each team employing comparative analysis from the U.S., Canada, Ireland, India and other nations in framing proposals for future laws or policies to be recommended for adoption in Northern Ireland.
Wednesday, November 27, 2013
About 80% of Continuing Care Retirement Communities (CCRCs) in the U.S. operate as 501(c)(3) tax-exempt organizations. Over time, what were once fairly humble establishments with strong church or fraternal organization ties, have expanded to serve the needs and interests of their clientele. In some instances, the facilities and amenities are now distinctly "high end," operating with lighter affiliations to religion or other charitable groups. Increasingly, for-profit management companies are hired to provide the day-to-day services.
Understanding the reasons to exempt CCRCs from federal income taxes takes a bit of history. For example, in 1972, the IRS issued Revenue Ruling 72-124, noting that providing for the "special needs of the aged has long been recognized as a charitable purpose" for Federal tax purposes. As such, a CCRC was viewed as relieving the distress of aged persons by providing for the primary needs of such individuals for housing, health care, and financial security. Thus, a CCRC could be treated as tax exempt under Section 501(c)(3) of the Code as an organization organized and operated exclusively for charitable purposes.
State and local tax authorities, however, may employ a more exacting standard on CCRCs in order to qualify for charitable tax exemptions, including property tax exemptions. For a thoughtful analysis of the different standards, see "The Commerciality Doctrine as Applied to the Charitable Tax Exemption for Homes for the Aged - State and Local Perspectives," by Professor David Brennan (Kentucky Law), published in Fordham Law Review in 2007, and still very relevant.
Tuesday, November 26, 2013
Via Yahoo News:
A man from Leeds, England has invented a dog-controlled washing machine. The "Woof to Wash" machine has a bark-activated "on" switch. A special "paw" button allows the pooch to easily open and close the machine's door. The inventor, John Middleton of U.K. laundry company JTM, intends for the "Woof to Wash" machine to make laundry an easier task for people living with disabilities by letting them delegate the trickier parts of the job to support dogs who have been trained to load and empty the machines. "We developed this machine because mainstream products with complex digital controls seldom meet the needs of the disabled user," he said. The Sheffield charity Support Dogs is training the animals to operate the new machines.
"People who are visually impaired, have manual dexterity problems, autism or learning difficulties can find the complexity of modern day washing machines too much," Middleton told Anorak. "I had been working on a single program washing machine to make things easier, and there was a lot of demand for it."
While working in Europe, I first heard the label "befrienders," as applied to people who work their way into the lives of disabled or elderly persons. The relationship often starts with the befriender doing small, helpful tasks; over time, the helper gains trust that enables him or her to have a greater role in the elder's life, thus opening the door to exploitation of the person's diminishing powers of judgment, while gaining complete control over finances.
On November 5, the New Hampshire Supreme Court affirmed convictions on nine of eleven criminal counts for "befriender" Karen Gagne, accused of stealing over $500,000 from a ninety year old woman in a retirement center. The case is State of New Hampshire v. Karen Gagne, 2013 WL 512499 (2013).
I plan to write more in the future about the technical details of the crimes charged in this context, but one of the clear lessons from the history in this particular case is how much time it may take for the befriending pattern to develop and "ripen" into fraud that is recognized by third-parties. For example, Karen Gagne's involvement with the victim spanned years:
"The defendant met the victim in the 1980s when the defendant performed landscaping services at the victim's home. The two became friends and subsequently lived together as companions in the victim's home for at least one year until the victim asked the defendant to move out. In the summer of 2006, the defendant and the victim rekindled their friendship. The victim moved to Pleasant View Retirement Home (Pleasant View), and the defendant began driving the victim to doctors' appointments and nail appointments, and taking her to lunch. In addition, although the victim had previously had an accountant pay her larger bills, the defendant began handling the victim's bills, including payment of her rent at Pleasant View."
At some point, "helpful" friend Gagne began liquidating the elder woman's annuities or other property and borrowing additional money under the elder's name.
The fact that Gagne was giving herself gifts might not have been discovered, except that by the fall of 2008, Gagne was no longer making regular rent payments to the retirement home. She offered excuses, such as blaming a "grandson or nephew" for stealing money, and claimed that she, Gagne, was trying to "recover" the money in order to pay the victim's bills. By late 2009, the victim was so far behind in rental payments -- and the excuses had become so unbelievable -- that the facility's executive director contacted the Attorney General's office, thus leading to the criminal charges.
Having sat through trials of similar cases, and having read transcripts of other cases, I can just imagine how Gagne would try to justify her thefts, arguing that "her friend wanted her to have the money" to explain why the 90-year old woman had "signed" checks she wrote out for her. In fact, this "gift" argument actually worked as a defense to two of the criminal counts in the case, where the older woman had personal involvement in transactions. Nonetheless, on the majority of criminal counts, the Supreme Court concluded "the defendant was not privileged to infringe upon the victim's interest" in joint accounts, nor was Gagne justified in misapplication of funds she was handling as a "financial representative" of the elder.
Karen Gagne was originally sentenced to "an aggregate of 10 to 30 years in New Hampshire State Prison for Woman." It is not clear from the opinion whether remand on the overturn of two of the elevent counts would trigger a resentencing.
New Hampshire, by the way, is the state that recently passed a new law, permitting long-term care facilities to sue "fiduciaries" who misuse assets of a resident, if that misuse results in "disqualification" of the resident for Medicaid, as we discussed earlier this month.
In central Pennsylvania, WITF, our local public radio station, has a great, daily, hour-long program wth "Smart Talk" on hot topics, often drawing upon local experts. Recently, the program was on hospice services and palliative care, and it sparked thoughtful conversation and dial-in questions. The program is now available as a podcast. November is "National Hospice & Palliative Care Month."
Monday, November 25, 2013
Understanding the expectations of a population cohort could help policymakers determine funding priorities. In "Baby Boomer Caregivers: Care in the Age of Individualization," published in a recent issue of The Gerontologist, Canadian researchers examine "how Baby Boomers in Quebec, Canada, perceive and play their role as caregivers and how this might differ from their parents’ generation." The study highlights the potential for Quebec's history of social services and the modern emphasis on careers for women to impact willingness of family members to assume at-home caregiving roles for spouses or parents:
"Indeed, in Quebec, the Baby Boomers have fully participated in the redefinition of the parental and grandparental structure by involving the (welfare) state as a “partner” in the distribution of services to the family.... Thus, Quebec caregivers like our participants differ from previous generations through the way they assume their caregiver identity as one among many social identities and refuse to define themselves only through their role as a caregiver. They say that they can do so thanks to their integration into the labor market coupled with the existence of public services."
The U.S. may not view itself as being a "welfare state," but is it likely that American Baby Boomers will have similar expectations about supportive social services?
Sunday, November 24, 2013
"Do Not Hospitalize" is the latest initiative in advance care directives, driven by emerging recognition of the variety of ways that individuals may not be well served by extra-ordinary care measures, requiring specific directions. The concept may require lawyers drafting traditional living wills to think more broadly. Further, the concept highlights the importance of families working directly with physicians who are sensitive to the larger dynamic.
I have to say this one hits home in my own family. My father, after physical health problems combined with larger frailty, declared at age 86, "I would rather die on the steps of the hospital" than spend another night there. That has been hard, at times, for my family to accept.
The New York Times in Judith Graham's "A Misunderstood Directive," provides a back story for the use of DNH orders. Dr. Michael Rothberg describes what occurred after his father-in-law, with severe dementia, was transferred from a care facility to a hospital for evaluation, a move that triggered even greater disorientation and reaction by the man, leading to restraints and medication. The theory of DNH is to provide a reasoned basis not to see hospitalization as the only option for patients, especially those with dementia:
"After another difficult hospitalization, this time for pneumonia, the family decided they didn’t want this vulnerable, distressed relative transferred from the nursing home again if he took ill. They asked that a “do not hospitalize” order be communicated to staff and placed in his medical record. Several months later, the patient stopped eating and drinking and passed away."
Dr. Rothberg and colleagues in Pennsylvania and Massachusetts have collaborated on a paper to describe and evaluate Do Not Hospitalize directives entered into by authorized agents (health care proxies or HCPs) for individuals with advanced dementia. They conclude:
"The potential barriers to and facilitators of HCPs initiating DNH orders identified in this study suggest that HCPs may benefit from more in-depth discussions with healthcare providers when making this decision. Interventions to address these barriers may improve the capacity of HCPs to make informed decisions about DNH orders that reflect individuals' values and wishes."
Friday, November 22, 2013
Via the Japan Times:
Humanitude, a caregiving method developed in France that emphasizes eye contact, touch and verbal communication to convey respect for the patient as a human being, is gaining attention in Japan for treating patients with dementia. Tokyo Medical Center in Meguro Ward, one of the hospitals adopting the Humanitude method, provides seminars for caregivers to expand its use. In a videotape shown at one such seminar, two nurses took a female patient with dementia to a shower. One nurse approached the woman from the front, looked at her at eye level and kept speaking to her gently while the other nurse washed her body with warm water.
The woman in her 70s, who was said to have screamed and refused to take a shower, was cooperative and remained calm, and even said that “the water temperature feels good.” The approach, with its name deriving from “human” and “attitude,” was developed about 30 years ago by Yves Gineste, who taught physical education, and his colleagues based on the philosophy of “what is humanity.”
The four basic pillars in the method are to look into the eyes of the patients, talk to, touch and help them stand upright. More specifically, particularly for elderly people with dementia, this means approaching from the front to avoid startling the patients, who tend to have a narrow range of vision; looking at them at eye level; telling them the procedures being conducted even if there is no response; avoiding gripping the patients’ wrists from above; and helping them stand upright or walk. There were remarkable scenes in the videotape that were taken in February last year when Gineste visited Tokyo Medical Center.