Thursday, February 4, 2016
My colleague Laurel Terry sent a link to this week's New York Times article that delves into the topic of "healthy aging." Thank you! While I can see "healthy aging"as a goal, I have to admit I had not thought carefully about what we mean with those words. Jane Brody's article, Finding a Drug for Healthy Aging, helps to explain, while also examining the latest push for medications that might serve the goal:
In 1980, Dr. James F. Fries, a Stanford University physician who studied chronic disease and aging, proposed that a “compression of morbidity” would enable most people to remain healthy until a certain age, perhaps 85, then die naturally or after only a brief illness.
Now, a group of experts on aging envisions a route to realizing Dr. Fries’s proposal: one or more drugs that can slow the rate of aging and the development of the costly, debilitating chronic ailments that typically accompany it. If successful, not only would their approach make healthy longevity a reality for many more people, but it could also save money. They say that even a 20 percent cut in how fast people age could save more than $7 trillion over the next half-century in the United States alone.
“Aging is by far the best predictor of whether people will develop a chronic disease like atherosclerotic heart disease, stroke, cancer, dementia or osteoarthritis,” Dr. James L. Kirkland, director of the Kogod Center on Aging at the Mayo Clinic, said in an interview. “Aging way outstrips all other risk factors.”
The practitioners of this field of study even have a name, geroscientists, "university scientists joined together by the American Federation of Aging Research to promote a new approach to healthier aging...."
Monday, January 25, 2016
Earlier this month I read an article about the role of brain inflammation in Alzheimer's. Scientists May Have Just Discovered the Key to Halting Alzheimer's was published on January 11, 2016 in Huffington Post Science. "Researchers at the University of Southampton in England conducted a series of experiments showing a chemical that reduces neuroinflammation may have the potential to protect against the memory and behavioral changes associated with the disease that affects roughly 5.3 million Americans." The article explains the research and notes that "[a]n overactive immune system can result in chronic inflammation, which previous research has linked to Alzheimer's. These new findings makes it increasingly apparent that inflammation is not a result of Alzheimer's as much as a key driver of the disease." Further research will be taking place. Exciting!
I think I might like winter better, if it always happened "conveniently" and with plenty of notice, as did Saturday's snow in Pennsylvania. For once, I was prepared to be at home, with a stack of good reading materials for catching up when the joys of house-cleaning and snow shoveling faded.
I am intrigued by the Fall 2015 issue of the NAELA Journal that focuses on how advances in genetic testing and medicine may be reflected in the roles of lawyers who specialize in elder and special needs counseling. A leading article in the issue introduces the three primary uses of modern genetic testing -- for diagnosis of disease, for determination of carrier status, and for predictive testing -- while reminding us there are limits to each function. In looking at age-related issues, the authors note:
Genetic testing is beginning to reveal information regarding susceptibilities to the diseases associated with old age: Alzheimer’s disease, Parkinson’s disease, diabetes, and cancer. Genetic test results showing a higher risk of such diseases can result in a cascade of consequences. Francis Collins, mentioned at the beginning of this article, responded to his test results thoughtfully by making lifestyle changes to reduce the probability that the increased genetic risk would be expressed in actual disease. It is important to note that, for some conditions, lifestyle factors’ influence on disease risk is understood; however, for many of the conditions that affect seniors, this influence is not yet known.
Other reactions to a high-risk test result may be more aggressive than diet and exercise changes. A well-publicized example is Angelina Jolie’s bilateral mastectomy. She was cancer-free but learned that she carries a BRCA1 mutation, which increases her lifetime risk for breast and ovarian cancer. She chose to undergo prophylactic mastectomy to reduce her breast cancer risk, whereas other women choose to increase breast cancer surveillance, such as undergoing more mammograms and breast MRIs. Both options are available to women who carry a BRCA1/2 mutation.
Will those found to be at elevated risk for more complex conditions such as Alzheimer’s disease or Parkinson’s disease make premature life choices, such as early retirement or marriage, based on perceived risk? Earlier in this article it is explained that an individual’s genotype rarely determines his or her medical destiny. For example, many people with a higher genetic risk for Alzheimer’s disease will not actually develop it, while many with no apparent higher genetic risk will. Is the risk that members of the general public will misunderstand and overreact to the results of a genetic test sufficient reason to prevent them from obtaining the information gleaned from such a test? Should we be ensuring that those undergoing genetic testing are aware of its benefits and limitations through individualized genetic counseling? This, of course, presents its own challenges of access and availability.
In reading this, it seems likely that lawyers may encounter complicated issues of confidentiality, especially when counseling "partnered" clients, while also increasing the significance of long-range financial planning and assets management.
For more, read Genetic Testing and Counseling Primer for Elder Law and Special Needs Planning Attorneys, by CELA Gregory Wilcox and Rachel Koff, Licensed Certified Genetic Counselor.
January 25, 2016 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Discrimination, Estates and Trusts, Ethical Issues, Retirement, Science | Permalink | Comments (0)
Thursday, January 21, 2016
I spent the first week of 2016 in Cuba with Dickinson Law students -- and it was an energizing experience (even as I fear I will never catch up on my other responsibilities this semester!). The students' studies in Cuba were wide-ranging, with opportunities to engage with experienced legal professionals while discussing historic principles and modern plans for Cuba, including a close look at laws adopted just in the last two years that will affect economic development, international investment in Cuba, employment, property ownership and taxes. For a full report on the course coverage and special events (including great photos by the students), see "Experience Beyond the Classroom Proves Invaluable."
For me, it especially interesting to hear directly about Cuba's health care system, which is highly regarded throughout the world, especially for its success in primary care for pregnant women. From Dr. Yoandra Adelá (depicted left) we learned core principles that guide Cuba's plans for health care, including a goal of universal coverage, free and equally accessible to all Cubans.
Our professors freely admitted challenges that Cuba faces in trying to meet health care goals in a struggling economy, with international partners important in order for Cuba to maintain access to medicines, technology and even credit needed to improve buildings and make necessary repairs at treatment sites.
Since 1985, Cuba has recognized a medical specialization in "comprehensive care" -- which emphasizes preventative medicine and community-based contacts. We saw this in action, where doctors from a local polyclinic spend half of their appointment days meeting patients in the office and half of those days seeing patients in their homes. We learned that for the elderly, many of the problems addressed by Cuban health care professionals mirror what is seen in the U.S., with hypertension and diabetes being significant health care risks; on the other hand, Cuba reports low incidence of infectious disease in their population.
I still need to learn more -- especially as I did not have time to fully explore "elder care," which reportedly includes some 380 hogares de ancianos and casas de abuelos, in addition to primary care offices that specialize in geriatric medicine. To the right is Corey Kysor, one of our law students visiting a Havana area polyclinic, the middle level of three components of health care available to all Cubans. (And yes, our law school does plan to return to Cuba in the next academic year to offer additional opportunities for comparative legal studies.)
If you would like to read more, from the perspective of a law student who had already experienced foreign legal systems such as China before traveling for her first time to Cuba this January, read Joy Lee's "Inside Cuban Law and Culture: A Law Student's Perspective."
Tuesday, January 19, 2016
Last summer, I blogged on news about the University of Southern California's controversial challenge to University of California-San Diego's position in Alzheimer's research, including USC's successful lure of top researchers (and their money). Lawsuits were unsuccessful in blocking the move, an attempt to avoid the loss of key research dollars.
However, the latest news is that UC-San Diego has "recruited a prominent Canadian neurologist to rebuild and lead" its Alzheimer's disease research program. From the news coverage:
Dr. Howard Feldman comes to La Jolla from the University of British Columbia in Vancouver, where he achieved international acclaim for his examination of dementia and for carrying out large-scale drug trials. A science journal nicknamed him the “master of dementia.” He’s also known as a rainmaker for his ability to raise money for research.
Feldman, 61, is receiving a recruitment package that includes $10 million to set up his laboratory and support his research program. His annual salary is $390,000.
Let's hope this means that there are now two stronger sites for research into diagnosis, treatment and cure for this dreaded disease.
Thursday, January 14, 2016
We do not think much about silence, perhaps especially in law school and as lawyers. In the law, we tend to ignore silence, typically referring expressly to silence in one of two contexts: (1) the right to remain silent (in the criminal law context) and (2) silence as constituting consent (in the contract law context). Silence is an overlooked area with tremendous potential for facilitating the practice of law and helping clients.
From this broad introduction to the potential significance of silence, in the second half of her article Professor Bassett focuses more specifically on older clients, and the subtle ways in which "age bias" can influence an attorney-client relationship. For example, she writes:
When lawyers quickly fill in silences by asking additional questions, one risk is that the lawyer’s questions may reflect inaccurate assumptions or even stereotypes. Suppose, for example, that a client seeks legal advice about drafting a will, and the client briefly stops talking. Uncomfortable with the silence, the lawyer rushes in to fill that silence by asking, “Do you want your children to receive everything?” That question reflects an assumption—a common assumption, but an assumption nonetheless—that parents always want to bequeath everything to their children. Perhaps the client indeed does want to leave everything to his or her children, but the lawyer’s preemptive question may cause the client to feel uncomfortable expressing a contrary desire.
Good fuel for discussion in a variety of courses.
My thanks to Dickinson Law Professor Laurel Terry for sending the link to this article.
Tuesday, January 12, 2016
We all know how important it is to get the appropriate amount of sleep. But it may be more important than we realize. According to an NPR story on January 4, 2016, Lack Of Deep Sleep May Set The Stage For Alzheimer's, we need that deep sleep to help us fend off Alzheimer's. The story focuses on the work of the Oregon Health & Science University scientists. One of the scientists explains why this deep sleep is so important to us: "[t]he brain appears to clear out toxins linked to Alzheimer's during sleep, [the scientist] explains. And, at least among research animals that don't get enough solid shut-eye, those toxins can build up and damage the brain." The story notes that there is definitely a link between sleep and Alzheimer's since many of those with Alzheimer's have some kind of sleep disorder. The OHSU scientists are about to start a study of "that should clarify the link between sleep problems and Alzheimer's disease in humans." The study described is fascinating (let's just say it involves sleeping in an MRI) and will be so important. Read more about the study here. Now, take a nap!
Tuesday, January 5, 2016
During this first week of January, I am in Cuba with a group of Dickinson Law students who are part of an introductory course on "Cuban Legal Systems." While we are in the country -- my second time here in less than 12 months -- I hope to continue to learn more about Cuba's demographics, including their reported successes on infant mortality, longevity and health care.
In the meantime, I came across an interesting photo essay from the National Geographic, providing a window into aging in Cuba. A key observation from Looking Into the Eyes of Cuba's Elderly, On the Verge of Change, is that Cubans "want tourists to come and experience their country but not just for salsa dancing, cigars and to see those amazing old cars -- but also to share stories about their countries, family, and lives...."
Monday, January 4, 2016
In a recent Associated Press article, Jimmy Carter Shows 90+ Age Not a Barrier to Major Surgery, the writers cite several examples of successful surgeries or advanced treatments for the most senior of senior citizens.
Irwin Weiner felt so good after heart surgery a few weeks before turning 90 that he stopped for a pastrami sandwich on the way home from the hospital. Dorothy Lipkin danced after getting a new hip at age 91. And at 94, William Gandin drives himself to the hospital for cancer treatments.
Jimmy Carter isn't the only nonagenarian to withstand rigorous medical treatment. Very old age is no longer an automatic barrier for aggressive therapies, from cancer care like the former president has received, to major heart procedures, joint replacements and even some organ transplants.
In many cases, the most senior citizens are getting the same treatments given to people their grandchildren's age — but with different goals.
"Many elderly patients don't necessarily want a lot of years, what they want is quality of life," said Dr. Clifford Kavinsky, a heart specialist at Rush University Medical Center in Chicago. "They want whatever time is left for them to be high quality. They don't want to be dependent on their family. They don't want to end up in a nursing home."
The article makes the point that "some 90-year-olds" are fitter than some 60-year-olds" and that age alone should not be the deciding factor. Indeed, in my own family we have faced major surgery questions with both my father and, more recently, my mother, and the result was a "different" decision in each instance, based on a whole host of factors. These can be tough calls.
Tuesday, December 22, 2015
I was listening to NPR's Morning Edition recently while working on this Blog and that's how I learned about a great resource, a telephone-based screening test for hearing problems, that individuals can take at home. Offered by The National Hearing Test, the cost is $5 (free for AARP members) and the process was developed with the help of an NIH grant. What impressed me is it tests for the ability to hear words (numbers) against background noise, a very realistic screen for many people's concerns. After taking the test, you are offered guidance and resources for follow-up. The NPR story made the point that unlike vision problems, which are hard to blame on others, it is all too easy for those with hearing problems to assume the problem "is" background noise or a failure of younger people to "speak up." Further, evaluation of hearing can be an important marker for other health issues, including problems with cognition.
For most reliable results, the website encourages you to use a traditional wired-phone connection, not a cell phone.
According to operation's website (linked above):
The National Hearing Test is provided on a nonprofit basis. It has no financial connections with any hearing products or services. (Free tests are typically offered by organizations selling hearing aids or providing services for a fee.) The $5.00 fee helps defray the costs of making it widely available to the public and processing test data; any remaining money goes to support further research on hearing loss.
Perhaps "taking" the screening test is a holiday present we can give our families.
Friday, December 18, 2015
Here's your new vocabulary word for the week -- "immunosenesence" -- and no, my spell checker doesn't recognize it as a word (yet). But the definition is interesting as the word refers to the gradual deterioration of the immune system that may accompany natural aging. Recent studies by researchers at the University of California San Diego and Emory University have focused on why older persons (defined in the study as over age 65) have weaker immune responses to seasonal flu vaccines. In turn, better understanding of the phenomenon may help to identify new approaches to immunizations for older persons.
The San Diego Union-Tribune offers a lay person's breakdown of the studies linked above.
Wednesday, December 16, 2015
I'm fascinated by technology and I've read several articles about the use of technology in caregiving for elders. With the proliferation of drone use by consumers, I was interested in the December 4, 2015 article in the New York Times As Aging Population Grows, So Do Robotic Health Aides. A robotics prof at the University of Illinois has a grant "to explore the idea of designing small autonomous drones to perform simple household chores, like retrieving a bottle of medicine from another room. Dr. Hovakimyan [the professor] acknowledged that the idea might seem off-putting to many, but she believes that drones not only will be safe, but will become an everyday fixture in elder care within a decade or two." The use of robotic caregivers is viewed as a way to help folks stay at home longer than now.
Can technology or robots be used to combat isolation and loneliness? The article turns to "Brookdale Senior Living, one of the nation’s largest providers of assisted living and home care... [which] is using a variety of Internet-connected services to help aging clients stay more closely connected with family and friends." According to the senior director of dementia care and programs at Brookdale, "there was growing evidence that staying connected, even electronically, offsets the cognitive decline associated with aging."
The article features several technologies under development, not just the drones which Dr. Hovakimyan refers to as “Bibbidi Bobbidi Bots." The article notes that Toyota is even getting into the field, noting that adding artificial intelligence to vehicles to make driving safer and to"make it possible for aging people to drive safely longer."
There are concerns about downsides to the use of such technologies, which are discussed in the article. The article turns to other countries leading the way in these advances and concludes with discussing a number of products currently on the market and how those may compare with in-person interactions.
Wednesday, December 9, 2015
Last month Kaiser Health News ran a story about a global initiative on dementia. New Brain Institute Plans To Refocus Third World’s Attention On Dementia As ‘Societal Issue’ explains the launch of an institute between University of California, San Francisco and the University of Dublin that is "aimed at helping developing countries learn more about the disease and cope with the burden it places on patients, families and caregivers." Known as the Global Brain Health Institute, both universities will house the institute. Focusing initially on Latin America and parts of the Mediterranean, the goal is to train a wide variety of professionals to understand dementia including prevention and delay. The press release from UC San Francisco is available here.
Monday, December 7, 2015
During my recent visit in England, I had the fortunate experience of having lunch with Bernard Casey, Associate Professor at the Personal Social Services Research Unit at the London School of Economics and Principal Research Fellow at the University of Warwick. He has deep interest and experience as a social economist in evaluation of the economic implications of societal ageing. We could have talked for hours -- so much so that I almost missed my train from London to Leeds.
Bernard introduced me to a fascinating network of academics and policy makers with related interests, the International Long Term Care Policy Network. I encourage you to check out their website, and especially to browse the short interviews with international experts who are following long-term care system developments around the world.
Mark Your Calendars: The ILP Network is hosting its 4th International Conference on Evidence-based Policy in Long-term Care at the London School of Economics and Political Science (LSE) in London from the 4th to the 7th of September in 2016. Key themes of the conference will include: care models, case management, economics of long-term care, equity and efficiency, funding systems, health and social care integration, housing, institutional dynamics, local vs. central policy interactions, personalization of the care system, policy implications of dementia, technology and long-term care, unpaid carers, and workforce and migrant workers. More information about registration and submission of abstracts will be available in the near future.
Monday, October 26, 2015
Recently I witnessed a nighttime accident on Interstate-81 in Cumberland County, Pennsylvania. There was an unmistakable "boom" signaling a rear-end collision. One truck (that appeared to be a large rental truck) had rear-ended an 18-wheeler behind me -- and I watched the faster moving rental truck continue past me on the road with heavy damage on its right side, before eventually veering to a shaky halt in the median. As far as I could tell, both drivers were alive, but at the first safe spot, I called 911.
I got off of I-81 at the next exit. I paused both for gas and to take a breath of crisp night air, before taking a back road the rest of the way home. While I was fueling, an older man in the car next to me, a car with West Virginia license plates, pointed to the I-81 overpass where traffic was crawling through more flashing lights. He asked, "Is it safe for us to get on the road to get home? We live about 75 miles from here." Frankly, I had no way to answer that with any confidence. He shook his head and said to his companion, "I think we should stay in a motel tonight."
Thursday, October 8, 2015
On October 4, CBS Sixty Minutes profiled self-driving cars. I kept expecting to see Becky Morgan on the program, given her interest in technology! I suspect, however, that she would be as perplexed as I was by the several comparisons of the car's speed controls to "driving like a little old lady."
At this point in development, even the most advanced design periodically signals for the human driver to take over when the car encounters un-preprogrammed facts. Plus, alas, the current version isn't prepared for driving in snow. Perhaps that's the consequence of all those engineers working on this in Silicon Valley in California.
Wednesday, October 7, 2015
PBS is premiering a six-part series on "The Brain with David Eagleman" on Wednesday evenings, beginning on October 14, 2015. It looks intriguing, with the following segments:
- What is Reality?
- What Makes Me?
- Who is In Control?
- How Do I Decide?
- Why Do I Need You?
- Who Will We Be?
The Albuquerque Journal recently profiled the creative mind behind this creative series. Neuroscientist David Eagleman grew up in Albuquerque although he now runs a lab for "Perception and Action" at Baylor University, where he also has a special interest in "neuroscience and the law."
Monday, September 28, 2015
Thomas Jefferson School of Law is hosting its second annual student writing competition focusing on disability law. The Crane Writing Competition, named in honor of a Thomas Jefferson alum, Jameson Crane III, seeks to encourage student scholarship at the intersection of law and medicine, or law and social services. A central purpose is to further development of legal rights and protections, and improve the lives of those with disabilities.
Who can enter? The competition is open to currently enrolled law students, medical students and doctoral candidates in related fields, who attend an accredited graduate program of study in the U.S.
Deadline for entries? January 15, 2016 (by midnight, Pacific Standard Time) via electronic submission. For details see the competition website at Thomas Jefferson School of Law: http://www.tjsl.edu/cranewritingcompetition
What will be your topic? The competition accepts papers on a wide range of topics related to disability law, including legal issues arising from employment, government services and programs, public accommodations, education, higher education, housing and health care. This should integrate well with students currently taking or who have recently completed a seminar course, thus allowing that all important "double value" for good papers.
Prizes include cash ($1,500 to first place; $1,000 for each of two second place winners), plus potential publication.
My thanks to Professor Susan Bisom-Rapp for sharing news of this year's competition. She is coordinating the competition and you can send questions directly to Susan.
Friday, September 11, 2015
In a recent decision in a complicated and long-running guardianship case, an appellate court in Illinois highlights a topic I'm seeing more and more often: How should courts "value" scores given by evaluators on mental status exams, especially when addressing guardianship issues?
The most recent opinion in Estate of Koenen, issued August 31, 2015, described testimony from multiple witnesses about the mental status of a man in a "plenary guardianship" proceeding. In two reports, from physicians chosen by the individual, the medical experts opined he was "capable of making his own personal and financial decisions." Another witness, a psychiatrist, was appointed by the court to evaluate the individual's "ability to make personal and financial decisions." Ultimately, the lower court concluded the individual was unable to manage his affairs.
On appeal, a central issue was the lower court's reliance on the court-appointed expert. Part of the psychiatrist's testimony was that the man "scored 26 out of 30, at the low end of the normal range" on the Montreal Cognitive Assessment (MOCA)" administered in January 2012, a test that was described by the court as a "twelve-minute test with standardized questions, as well as writing and 'copying' tests." The psychiatrist also testified that in January 2013 he tested the man again with a score on the MOCA that was "now 22 out of 30 which was 'fully consistent with dementia.'"
Ultimately, the appellate court affirmed the lower court's decision, noting the extensive use of interviews and other data collection by the court-appointed physician to support the findings of incapacity. The appellate court seemed interested however, in the actual number scores, taking note that the court-appointed expert discounted scores reported by the individual's preferred physicians on "Folstein or 'mini-mental' examination[s]" on the grounds that the MOCA test was more sensitive "for dementia."
Reading this challenging case is a reminder of the ABA-APA Handbooks, for attorneys, psychologists, and judges, on assessing capacity of older adults. The Handbook for Judges describes a host of cognitive and neuropsychological testing tools, although it appears neither the MOCA test or the Folstein test is described. Is "standardization" of testing for purposes of legal capacity decisions needed?
Thursday, July 30, 2015
As detailed in new stories in Southern California media, an important suit by University of California San Diego (UCSD) against University of Southern California (USC) highlights a battle between public and private research enterprises. Control over millions of dollars is stake for Alzheimer's-related research. From the San Diego Union-Tribune in a Sunday feature article by Larry Gordon, Gary Robbins and Bradley Fikes:
In the lawsuit, U.C. San Diego alleges that USC, [Alzheimer's researcher Paul] Aisen and eight colleagues conspired to take research data involving more than 1,000 patients and other assets, including an estimated $100 million in federal and private funding to a new Alzheimer's study center in the San Diego Area. Aisen and USC deny any wrongdoing and contend that UC San Diego is trying to inhibit the freedom to move jobs and is threatening the data's security.
A Superior Court judge in San Diego last week denied USC's request to block UC San Diego's access to that data.
Richard Seligman, the associate vice president for research administration at Caltech who has more than four decades of experience dealing with grants, said he had never heard of such a lawsuit even though competition for grants and noted faculty has gotten more fierce.
Stakeholders interested in the outcome of the research are reported to be taking note of the suit, with Mary Carrillo, the chief science officer for the Alzheimer's Association quoted as saying the association wants a "speedy resolution" of the lawsuit to keep research going forward.
Left in an uncomfortable middle ground are the National Institutes of Health and its subsidiary National Institute on Aging, which provides about $11 million per year to the UC Alzheimer's Center. While confirming that UC San Diego still holds that grant, officials at those agencies said they must approve whether funding like that stays put or moves to another school with a principal investigator like Aisen.
For additional background on the lawsuit, see a related Los Angeles Times piece here. Reporters from the Los Angeles Times and the San Diego Union-Tribune have collaborated on these stories.
On Friday, July 24, a California trial court ruled that the key research data must be returned to UCSD and therefore does not go "with" the faculty member, Aisen, recruited away from San Diego by USC. Details here.
As further evidence of the battle for primacy in southern California medical research, USC and UCSD have each courted the La Jolla Institute for Allergy and Immunology, with University of California-San Diego energing as the winning suitor for "affiliation." Details here.