Monday, February 12, 2018

Kaiser Health Offers Q & A on "Living Well with Dementia" on Tuesday, Feb 13

Sorry for the late news but Kaiser Health News is offering a live discussion via Facebook Live! and Twitter on "Living Well with Dementia" on Tuesday, February 13, from 12:30 to 2:00 p.m. Eastern Time.

Hear are details:  

Join Kaiser Health News on Tuesday, Feb. 13, from 12:30 to 2:00 p.m. ET for an informative and important discussion about improving care and services for people with dementia and supporting their caregivers. It’s an opportunity to learn from experts in the field about the challenges and difficulties facing the patient, the caregiver, the community and policymakers. Topics will include understanding the stages of dementia from a medical, social, psychological and environmental perspective (it’s not just memory loss); how to find help; how to manage difficult behaviors; and understanding medications for people with dementia. 

Kaiser Health News’ “Navigating Aging” columnist Judith Graham will moderate a discussion with you and a panel of experts as we explore this issue.

Our panelists are:

  • Nancy A. Hodgson, Ph.D., RN, FAAN, University of Pennsylvania, an expert on dementia care and end-of-life care for people with dementia; 
  • Helen Kales, M.D., University of Michigan, a geriatric psychiatrist and expert on dementia care and mental health issues; 
  • Yvonne Latty, BFA, MA, a journalist and professor, who is dealing with her mother’s Alzheimer’s;
  • Katie Maslow, MSW, Gerontological Society of America, an expert on improving care for people with dementia and supporting their caregivers; and
  • Mary L. Radnofsky, Ph.D., a former professor who lives independently since being diagnosed twelve years ago with dementia and is an advocate for people with dementia.

February 12, 2018 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Science | Permalink | Comments (0)

Monday, January 22, 2018

Increasing Awareness and Understanding of Frontotemporal Dementia

A good friend and Penn State colleague, Dr. Claire Flaherty, a neuropsychologist at Penn State Hershey Medical Center, was part of a recent program explaining frontotemporal dementia, a condition which is often subtle, but nonetheless potentially devastating, especially when misdiagnosed.  Here's the link to the podcast of the program, from a local television station in Pennsylvania. 

 

 

January 22, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Science | Permalink | Comments (0)

Wednesday, January 17, 2018

What Does it Mean to Have a "Perfect Score" on a Cognitive Assessment Test?

I've sat in on dozens of mental acuity screening exams for individuals exhibiting indications of some form of dementia.  

Regarding the "perfect score" reportedly received by President Donald Trump on a mental acuity screening test during his January health exam, it may be helpful to consider what is -- and isn't -- covered by such assessments.  One view is provided in an opinion piece this week in the Washington Post, using history from a criminal case where Brooke Astor's son and an attorney were found guilty of exploiting her alleged mental incapacity.    From the article: 

On its surface, the Montreal Cognitive Assessment (MoCA) test seems pretty easy. Can you draw a three-dimensional cube? Can you identify these various animals? Can you draw a clock? Can you repeat back the phrase, “The cat always hid under the couch when dogs were in the room”? . . . 

 

If you look at the test, it’s pretty hard to see how you could not score a 30. You see a picture of a lion and have to identify it as a lion? That old joke about how the elderly and toddlers are subject to the same indignities seems pertinent here: Is this really the bar that needs to be met to demonstrate full mental capabilities?

 

Well, according to those who study dementia and other mental deterioration, yes.

 

In 2009, I spent six months serving on a jury in the state of New York that was asked to judge the guilt or innocence of a man named Anthony Marshall. Marshall was the son of Brooke Astor, a New York socialite and heiress to the much-diminished Astor fortune. If you’ve ever traveled to New York, you’ve encountered the name: Astor Place, the Waldorf-Astoria or the Astoria neighborhood in Queens. Marshall was accused of having taken advantage of Astor’s diminished mental state to change her will without her being aware of the changes made. Ultimately, the 12 members of the jury found Marshall guilty of several charges.

 

Over the course of that trial, we were presented with a great deal of information about how doctors assess the mental capabilities of a patient. This was critical to the prosecution; were they not able to prove that Astor’s mental state was diminished, it undercut their argument that Marshall had acted without his mother’s consent. As such, expert witnesses testified about their personal examinations of Astor and others spoke to the reliability of the tests.

 

Central to that case was one of the components of the MoCA test: drawing a clock. Astor was asked repeatedly to draw analog clocks as a test of her mental acuity. On more than one occasion, she was unable to do so properly. . . . 

 

The point is not that the test is easy. The point is that an inability to complete aspects of the test reveals different types of mental decline. The clock test is about executive brain function: memory, planning ahead. The different parts of the MoCA are labeled according to what they test, with the clock test falling under “visuospatial/executive.” Questions about the current year and date are under “orientation.” The request to identify a drawing of a camel is under “naming.” In the test’s scoring instructions, it explains what is covered: “attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations and orientation.”

 

It is, as Trump’s doctor noted, a tool for identifying early signs of mental deterioration, like the mental version of a blood sample on which your doctor runs a battery of tests. It’s not the SAT; it’s a screening device.

For more, read Why You May Be Misunderstanding the Mental Test that Trump Passed with Flying Colors, by Philip Bump.

January 17, 2018 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Discrimination, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Science | Permalink | Comments (0)

Tuesday, January 16, 2018

Oh Those Boomers: Reaping the Impact of Loud Music

Those Boomers (or should I say, more accurately, we boomers). We invented lots of things (if you ask us) including rock 'n roll and now we are experiencing hearing loss. It was only a matter of time.... after years of playing all that rock music so loudly (of course our parents warned us), we are reaping the after effects-hearing loss (this is a tongue in cheek statement, BTW). Baby boomers destroyed their hearing. Biotech is trying to fix it 

opens with these paragraphs

Baby boomers grew up with music blasting from dorm room turntables, car stereos, and arenas where the sound of a band at full throttle could rival the roar of a jet engine. Volume became an act of generational defiance. As rocker Ted Nugent put it: “If it’s too loud, you’re too old.” ... Turns out, it was too loud. Millions of boomers are now grappling with hearing loss — some of it caused by turning the volume to 11 — prompting companies to develop treatments that improve upon the expensive and often limited-value hearing aids and surgical implants that have been around for decades.

Intrigued. Find yourself amongst those who maybe played your music at "11"?  Want to read more?  The Boston Globe also an the article.  The article looks at the frequency (no pun intended, honestly) of hearing loss and it's a lot, the treatments being researched, and more. And before you go off to tell your children to turn down the volume on their music, the article notes noise isn't the only reason for hearing loss. Some of it is genetic and another is age related. Technology plays a role as well, with one expert noting the impact of leaf blowers and ear buds.  Different devices and developing drugs are being studied as an option for those with hearing loss.

January 16, 2018 in Consumer Information, Current Affairs, Health Care/Long Term Care, Other, Science | Permalink | Comments (1)

Monday, January 8, 2018

The Challenge of Finding Safe & Effective Pain-Killers for Older Adults

Over the holidays, unfortunately I had the experience of learning more about how older consumers struggle to understand what safe and effective treatments are available.  In this instance, my mother, in her 90s, was experiencing overwhelming back pain.   She has a long-history of osteoporosis (and it runs in the family on the female side, so my sister and I pay particular attention to this issue!) and in the last few weeks without any known "accident," she had begun to find it almost impossible to walk without pain.  She's not the complaining type, and, having been raised by parents who were Christian Scientists, she tends to follow a "mind over matter" approach to this kind of problem.  But, by Sunday last week, it was no longer possible to pretend she wasn't deeply uncomfortable.

We began another health care odyssey.  Some of the steps we had already learned from past "holiday" experiences with my parents, including calling the "non-emergency" 911 number to get an experienced EMT evaluation of her status in the home, and, if necessary, a transport from her home to the emergency room.  Then, recognizing that New Year's Eve is probably not the best night (if such a thing even exists) to spend in the local hospital's ER, we decided to go early in the morning.  

Five hours after our arrival in the ER, we left with a new "LSO" back brace, instructions on how to use it, and prescriptions for a different walker and a new pain medication.  On the latter point, we informed the ER physician of the fact Mom had not done well on narcotic pain relievers in the past ("why are those ants crawling on the walls") but we were told the drug prescribed was like a very strong Ibuprofen, but in a formulation that would not interact with the blood thinner she was on or her pacemaker.

We duly stopped at the pharmacy on the way home, and I signed my life away in order to pick up her prescription as she was unable to walk in to get it herself.  When we got home,  there were two documents in the bag with the prescription, including what I would call a typical "product insert" that looks like a page from the Physician's Desk Reference and a second sheet entitled "Directions for Use."  The top of the instructions warned, "This is a narcotic drug and not recommended for the relief of pain in...."  And then the list of disqualifying conditions included at least 3 of my mother's age-related conditions.  Yikes!  

My sister and I are  not usually intimidated by product inserts, but here the instructions seemed directly at odds with our concerns about narcotics for mom.  Everything we found on the internet only made us more confused and worried.  

By this time it was late on New Year's Eve, her pain was increasing, and we knew we couldn't persuade her to go back to the ER and her primary care physician wasn't on call.  The bottle said "every 6 hours."  The ER physician had orally told us "every 6 to 8 hours," and finally we knew we had no choice -- her pain was real and we started using it at 12 hour intervals, gradually moving down to 8 hour intervals before she seemed to have real relief.  It was another 5 days before her very kind primary care physician could squeeze us in for an appointment to have a more complete conversation -- and the good news is that we are now more comfortable about a longer range plan.

So on the heels of that multi-day experience, I was very interested in an article I spotted for my airplane trip home to Pennsylvania from Arizona. Phoenix Magazine had a detailed feature story in their January 2018 issue on "Pharma Chameleon," reporting on the arrest for fraud and racketeering charges of INSYS  Therapeutics founder, a "billionaire executive" in Phoenix, well-known for his work on painkiller medicines.  The history of this executive has nothing to do with my mother's pain relief medicine, but it was definitely a reminder that the pharmaceutical industry is deeply involved in pursuit of the "next" generation of painkillers.  And, of course, this article contrasts with the recent news that a different drug company is dropping R & D for a dementia drug.  Pain-killers are still "in," and dementia drugs apparently are "out."  

So, I recommend the Phoenix Magazine article!  I was particularly struck by this paragraph:    

In November, Kapoor [the Phoenix-based INSYS executive arrested by the feds] pleaded not guilty to all charges and is currently awaiting trial, along with the six other former executives, who pleaded not guilty last January. All have severed ties with INSYS, which continues to do business. In July, it received FDA approval for a new drug, Syndros, a synthetic form of THC, the psychoactive component found in cannabis, to treat chemotherapy-induced nausea and loss of appetite in AIDS patients. As it did with Subsys, the company is looking into ways to manufacture the drug as a sublingual spray. Under Kapoor, the company donated $500,000 to the effort to defeat the measure to legalize marijuana for recreational use on Arizona’s 2016 general election ballot, paving the way for the synthetic substitute.

January 8, 2018 in Consumer Information, Crimes, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Science, State Cases, State Statutes/Regulations | Permalink | Comments (1)

Sunday, January 7, 2018

Pfizer Inc. Announces It Will End Research on Alzheimer's & Parkinson Drugs

According to the Wall Street Journal, Pfizer Inc released a public statement on Saturday, January 6, 2018, announcing the end of R & D for new drugs for treatment of Alzheimer's Disease and Parkinson's Disease.  The announcement reflected cost of efforts and the lack of success, and apparently the decision will mean layoffs for some 300 employees "over several months."

The Wall Street Journal also provided context for the disheartening decision:  

Like several peers, Pfizer has invested heavily in developing treatments for Alzheimer’s and Parkinson’s because of the huge need. About 5.5 million Americans have Alzheimer’s, and the numbers are expected to rise as the population ages. Analysts say successful treatments for the memory-robbing disease could have multibillion-dollar sales potential.

 

But promising compound have repeatedly failed to work during testing.

 

Notably, in 2012, Pfizer and partner Johnson & Johnsonhalted development of an Alzheimer’s drug called bapineuzumab after it failed to slow memory loss in test subjects.

 

The most recent disappointment took place last year, when a closely watched study of a treatment from Axovant Sciences Inc. called intepirdine failed to improve memory and learning in Alzheimer’s patients.

Companies that are still looking at possible Alzheimer's treatments include AstraZeneca, Biogen Inc, and Eli Lilly & Co., according to the WSJ article.  

January 7, 2018 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Science | Permalink | Comments (1)

Wednesday, December 13, 2017

"Snake Oil," Tattoos & Why Some Hospice Doctors Prefer Medical Powers of Attorney

Are games and food supplements that promise to stave off the onset of dementia the modern day version of "snake oil?" I promised to write more about the Aging Brain Conference at Arizona State University's Sandra Day O'Connor College of Law on December 8, 2017.  Speaker Dr. Cynthia Stonnington, Mayo Clinic, offered an important look at ways in which law, ethics, medicine, and commerce can collide with her survey of a host of approaches receiving "popular" press treatment.  

She examined self-described "brain-training" programs, miracle diets, supplements and targeted exercise programs, noting that most studies that purport to demonstrate positive results from these items have serious flaws.  Thus, at best, programs that claim to provide "protection" against dementia are usually promising more than has been proven.  Dr. Stonnington, along with the morning keynote speaker, former U.S. Surgeon General Richard Carmona, reminded us that

  • maintaining social engagement,
  • engaging in lifelong learning,
  • getting regular exercise of any type,
  • having good blood pressure control,
  • getting adequate sleep, and
  • focusing on good nutrition (including eating plans such as the Mediterranean, DASH or MIND diets)

are  far more important than any single, magic game or exercise.

One of the most lively discussions of the day came near the end, in response to presentations by Dr. Patrica Mayer of Banner Health in Phoenix, Amy McLean of Hospice of the Valley. and Life Sciences Professor Jason Robert (ASU) speaking for himself and Susan Fitzpatrick (James S. McDonnell Foundation), about end-of-life considerations for persons with dementia or other serious illnesses.  What would be the most likely response of a physician or emergency personnel confronted with a "do not resuscitate" tattoo on the chest of an emergency patient?  Dr. Mayer stressed that she is seeking reliable methods of communicating end-of-life wishes, and for her that means a preference for a written, Medical Power of Attorney.  She wants that "live" interaction whenever possible, in order to fully explore the options for care for individuals unable to communicate for themselves.  But she also noted a frequent frustration when she contacts designated  POAs about the need to make tough decisions, only to learn they were completely unaware before that moment of having been named as the designated agent.  

LSI_Aging Brain 120817 Competency_and_Incapacity_1 SPEC (1)I was part of a panel of court-connected speakers, including Arizona Superior Court Judge Jay Polk (Maricopa County), neuropsychologist  (and frequent expert witness) Elizabeth Leonard, and experienced Phoenix attorney Charles Arnold.  I was interested to hear about  -- and will pursue more information on -- the psychologists' use of evaluative tools for clients that use scenarios that would appear to test not just for loss of memory, but impaired judgment.  I was speaking on the unfortunate need for judicial inquiries into "improvident transactions" by persons with problematic cognition and I used litigation approaches from other locations -- Ireland (common law) and Maine (statutory) -- as examples.  The Arizona legal experts reminded me to take a closer look at Arizona's financial exploitation laws.

For more from this conference, see Learning to Say the Word "Die"  --  about a pilot program developed by Dr. Mayer while she was an advanced bioethics fellow at the Cleveland Clinic.  I also recommend Dr. Mayer's article on CPR & Hospice: Incompatible Goals, Irreconcilable Differences

 

December 13, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Games, Health Care/Long Term Care, Legal Practice/Practice Management, Programs/CLEs, Science, Statistics | Permalink | Comments (0)

Tuesday, December 12, 2017

Legal Implications of Biomarkers for Dementia Highlight ASU's Conference on "The Aging Brain"

The "Aging Brain" Conference hosted by Arizona State University's Sandra Day O'Connor College of Law held on December 8, 2017 at the Sandra Day O'Connor United States Courthouse in Phoenix (that's a double helping of Sandra!) proved to be a fascinating, deep dive into the intersection of medicine, ethics and law with a focus on neurocognitive diseases, including Alzheimer's Disease.  The panelists and audience included academics in a wide range of fields, plus practitioners in medicine, law, social services, and more, along with both state and federal judges.  United States District Judge Roslyn Silver is a long-time supporter of law and science programming with ASU. LSI_Aging Brain 120817 Competency_and_Incapacity_5 SPEC (2)

One of the important themes that emerged for me was the growing significance of pre-symptomatic tests that can disclose genetic markers associated with greater incidence of an eventual, active form of a degenerative brain disease.  Neurologist Richard Caselli from Mayo Clinic and Jessica Langbaum, principal scientist with Banner Alzheimer's Institute laid out the latest information on a variety of genetic testing options, including the possibly mixed results for "risk" connected to positive results for specific genetic markers.  A provocative question by a morning speaker, Law and Biosciences Professor Henry T. Greely at Stanford, captured the personal dilemma well, when he asked the audience to vote on how many would want to to know the results of a genetic test that could disclose such a connection, especially as there is, as yet, no known cure or even any clear way to prevent most neurocognitive diseases from taking hold.  

Taking that a step further, how many of us would want our employer to know about that genetic marker results?  How about our health insurers? As we discussed at the conference, some consumer information is already available through "popular" ancestry testing sites such as "23 and Me," which expressly offers testing for "genetic health risks," including "late-onset Alzheimer's Disease and Parkinson's Disease."  Arizona State Law Professor Betsy Gray, director of the Law & Neuroscience Program for ASU's Center for Law, Science and Innovation, who master-minded the conference, helped to identify a host of legal and ethical issues connected to this developing world of science and medicine. Jalayne J. Arias, a full-time researcher at University of California San Francisco's Neurology, Memory and Aging Center (and clearly a rising academic star and graduate of ASU Law) outlined the implications of pre-symptomatic testing from the perspective of long-term care insurance.  For more from Professor Arias, I recommend her 2015 paper for the Journal of Clinical Ethics on Stakeholders' Perspectives on Preclinical Testing for Alzheimer's Disease.

 I plan to write more about this conference, as many perspectives on legal, ethical and medical questions were offered.      

December 12, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Discrimination, Ethical Issues, Programs/CLEs, Science | Permalink | Comments (0)

Wednesday, December 6, 2017

Arizona State Presents Legal, Policy and Ethical Perspectives on "The Aging Brain"

On December 8, 2017, I'm excited to be participating in a conference on The Aging Brain: Legal, Policy & Ethical Perspectives, in Phoenix, Arizona.  This program is a follow-up to an interdisciplinary workshop hosted at Arizona State University's Sandra Day O'Connor School of Law in the fall of 2016. This year's presentations will take place at the the United States Courthouse in Phoenix.

The planned schedule is jam-packed with speakers I'm looking forward to hearing, including:

Welcome: Betsy Grey, Sandra Day O’Connor College of Law, ASU

Introduction: Dean Douglas Sylvester, Sandra Day O’Connor College of Law, ASU

Keynote Speaker:Richard H. Carmona, M.D., M.P.H., FACS, 17th Surgeon General of the United States, Chief of Health Innovations, Canyon Ranch, Distinguished Professor, University of Arizona

Scientific Developments in Aging and Dementia: Pre-Symptomatic Screening for Neurodegenerative Diseases

    Panel Chair: Hon. Roslyn O. Silver, U.S. District Court for the District of Arizona

  • Dr. Richard Caselli, Mayo Clinic
  • Dr. Jessica Langbaum, Banner Alzheimer's Institute
Ethical, Legal, and Social Implications
       Panel Chair:  Michael Saks, Sand Day O'Connor College of Law
  • Dr. Cynthia M. Stonnington, Mayo C;inic
  • Jalayne J. Arias, UCSF Neurology, Memory and Aging Center
  • Henry T. Greely, Stanford Law School

Aging at Home

    Panel Chair: Larry J. Cohen, The Cohen Law Firm

  • David Coon, College of Nursing & Health Solutions, ASU
  • Kent Dicks, Life365, Inc.
Competency and Incapacity: Assessment and Consent

    Panel Chair: Charles L. Arnold, Frazer Ryan Goldberg & Arnold, LLP

  • Hon. Jay M. Polk, Probate Dep’t. Associate Presiding Judge, Superior Court of Arizona for Maricopa County
  • Katherine Pearson, Dickinson School of Law, Pennsylvania State University
  • Dr. Elizabeth Leonard, Neurocognitive Associates
  • Betsy Grey, Sandra Day O’Connor College of Law, ASU

End of Life

    Panel Chair: Dr. Mitzi Krockover, Health Futures Council at ASU

  • Jason Robert, Lincoln Center for Applied Ethics, ASU
  • Amy McLean, Hospice of the Valley
  • Dr. Patricia A. Mayer, Banner Baywood & Banner Health Hospitals

Keynote:

Dr. Susan Fitzpatrick, President, James S. McDonnell Foundation
Introduction by Jason Robert, Lincoln Center for Applied Ethics, ASU

December 6, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Federal Cases, Health Care/Long Term Care, Science, Statistics | Permalink | Comments (0)

Tuesday, November 21, 2017

New Publication: Old & Sick in America

Dr. Muriel Gillick, a Professor of Population Medicine at Harvard Medical School and the director of the Program in Aging at Harvard Pilgrim Health Care Institute had a new book.  Old & Sick in American: The Journey Through the Health Care System sounds like it hits the nail on the head, demonstrating topics that a wise consumer will need to recognize in order to navigate biases and weaknesses in the system. 

For a timely Q & A interview with the author, see How Older Patients Can Dodge Pitfalls Entrenched in Health Care System, published by California Healthline. 

November 21, 2017 in Books, Consumer Information, Health Care/Long Term Care, Medicaid, Medicare, Science | Permalink | Comments (0)

Wednesday, November 15, 2017

Shortages of Specialists to Screen and Diagnose Early Stages of Neurocognitive Diseases Are Part of the Looming Problem

A recent study by the Rand Corporation points to related problems with diagnosis AND  treatment of Alzheimer's Disease and other neurocognitive disorders. Even as there is a growing need for effective treatment, there are "too few medical specialists to diagnose patients who may have early signs of Alzheimer's" and thus become eligible for therapies that might slow or or halt progression of such diseases.   From the Rand news release:  

“While significant effort is being put into developing treatments to slow or block the progression of Alzheimer's dementia, little work has been done to get the medical system ready for such an advancement,” said Jodi Liu, lead author of the study and a policy researcher at RAND, a nonprofit research organization. “While there is no certainty an Alzheimer's therapy will be approved soon, our work suggests that health care leaders should begin thinking about how to respond to such a breakthrough.”

 

An estimated 5.5 million Americans live with Alzheimer's dementia today, with the number projected to increase to 11.6 million by 2040.

 

Advanced clinical trials are underway for at least 10 investigational therapies that have shown promise in slowing or blocking development of Alzheimer's disease. Researchers say the progress provides guarded optimism that a disease-modifying therapy could become available for routine use within a few years.

 

Liu and her team examined the pathway patients would likely take to receive an Alzheimer's therapy and created a model to simulate the pressures that such an approved therapy would put on the health care system.

 

The analysis assumes that a therapy is approved for use beginning in 2020 and screening would begin in 2019, although researchers stress that the date was chosen only as a scenario for the model, not as a prediction of when a therapy may be approved.

 

Under such a scenario, about 71 million Americans aged 55 and older would have to be screened for signs of mild cognitive impairment. After follow-up examinations and imaging to confirm evidence of Alzheimer's, the RAND analysis estimates 2.4 million people ultimately could be recommended for treatment.

For additional analysis, see The Washington Post's article from its Business Section, We're So Unprepared for Finding An Alzheimer's Treatment. 

Special thanks to George Washington Law Professor (and friend) Naomi Cahn for making sure we did not miss this item.  

November 15, 2017 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Federal Statutes/Regulations, Health Care/Long Term Care, Science | Permalink | Comments (0)

Tuesday, October 31, 2017

What Happens When the Diagnosis of "Alzheimer's" Isn't the Correct Diagnosis?

On Monday I did a presentation in New Orleans for a conference sponsored by a professional liability insurance organization. My topic was "legal implications of a diagnosis of dementia" as a risk management concern and part of my task was to talk about alternative diagnoses of neurocognitive disorders, especially for clients. 

In part, my message was a note of caution.  Lack of "short term memory" may not be present, and thus attorneys, families and colleagues may not have this early warning sign of cognitive disease.  For example, a frontal lobe disorder can be "early" onset (usually meaning onset before the individual reaches the age of 60).  Language or short term memory problems may not be noticeably impaired, while higher executive functions, especially judgment, can be seriously impacted.  Changes in personality, loss of inhibition (including sexual inhibition), recklessness with money or investments may be signs, but these changes may be mistaken for "a mid-career crisis," or other personality problems unrelated to disease.   

The lawyer who invited me to do this program with him, Mark Tuft from California, has long experience and knowledge of ethical and disciplinary standards for attorneys.  On a related point, he pointed me to a recent Washington Post article, where an individual had been living for two decades with a "fatal" diagnosis of early onset "Alzheimer's Disease," which, as it turns out, may not have been accurate.  The author writes in his essay:  

Two neurologists have stated [recently] that I fall into a fairly new category called suspected non-Alzheimer’s pathophysiology, or SNAP. According to one study, about 23 percent of clinically normal people ages 65 and older and about 25 percent of people with MCI[Mild Cognitive Impairment] have SNAP. For people with both MCI and SNAP, the risk of cognitive decline and dementia is higher than for clinically normal people with SNAP.

 

I was initially diagnosed with MCI. But for the past 10 years, the diagnosis has been Alzheimer’s. It is still officially the diagnosis because information gained in trials — which is how I found out that my amyloid scan was negative and that I probably did not have Alzheimer’s — does not go on a medical record. . . . 

 

I will have to wait for science to catch up before I know for sure. Who knows, I may even be part of the next new term. I just hope it means that what I have will not be progressive and lead to death. The one thing we all should learn from my experience is to take advantage of all the tools we have access to so we can make the best decision possible.

What is next for this individual? He received the latest news with mixture of relief and confusion. Read "I lived with an Alzheimer’s diagnosis for years. But a recent test says I may not have it after all," by 

Thanks, Mark, for sharing your podium in New Orleans with me on Monday and for pointing all of us to this article, which is another reminder of the rapidly changing world of scientific knowledge about cognitive impairments. 

October 31, 2017 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Health Care/Long Term Care, Science | Permalink | Comments (0)

Monday, October 23, 2017

The Latest in Off-Label Prescriptions for Dementia Patients: "The Little Red Pill"

My thanks to my colleague Dermot Groome for pointing me to the CNN investigative series on "The Little Red Pill Being Pushed on the Elderly." The prescription drug in questions is Nuedexta, approved to treat PseudoBulbar Affect or PBA, a "disorder marked by sudden and uncontrollable laughing or crying." (Perhaps you have seen commercials for treatment of PBA with actor Danny Glover effectively portraying the disorder).   

According to the CNN report:

Since 2012, more than half of all Nuedexta pills have gone to long-term care facilities. The number of pills rose to roughly 14 million in 2016, a jump of nearly 400% in just four years, according to data obtained from QuintilesIMS, which tracks pharmaceutical sales. Total sales of Nuedexta reached almost $300 million that year.
 
Concerns about unnecessary prescription, side effects (including a higher incidence of falls), and federal reimbursements for cost are raised by critics:
 
Nuedexta is approved by the Food and Drug Administration (FDA) to treat anyone with PBA, including those with a variety of neurological conditions such as dementia. But geriatric physicians, dementia researchers and other medical experts told CNN that PBA is extremely rare in dementia patients; several said it affects 5% or less. And state regulators have found doctors inappropriately diagnosing nursing home residents with PBA to justify using Nuedexta to treat patients whose confusion, agitation and unruly behavior make them difficult to manage.
 
 
"There has to be a diagnosis for every drug prescribed, and that diagnosis has to be real ... it cannot be simply made up by a doctor," said Kathryn Locatell, a geriatric physician who helps the California Department of Justice investigate cases of elder abuse in nursing homes. "There is little to no medical literature to support the drug's use in nursing home residents (with dementia) -- the population apparently being targeted."
The article notes that Medicare pays for much of the use of this drug in the nursing home setting, and as we've been reported before on other off label prescriptions of  medications, federal regulators have the power to investigate and sanction improper use (not just off-label use) under the False Claims Act and similar anti-fraud regulations.  

October 23, 2017 in Cognitive Impairment, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Medicare, Science, Statistics | Permalink | Comments (0)

Friday, October 6, 2017

Guns, Aging & Suicide

The last few weeks have been very tough, haven't they?  As have the last few months, and perhaps even the last few years.  

Many seem to be trying to understand why a 64-year-old "retired" man in the U.S. would assemble an arsenal of weaponry, unleash it on a crowd of innocents enjoying a last few weekend hours of music, and then take his own life.  While it is, on a comparative scale, unusual for a 60+ individual to be involved in a mass shooting, "older men" apparently have a comparatively high suicide-by-gun rate.  While there may be no way to understand the motivation for the most recent murders, there are still reasons to ask whether aging and deteriorating cognitive health can be factors in gun-related deaths.  

In the search for some understanding I read Leah Libresco's opinion piece in the Washington Post:  "I used to think gun control was the answer.  My research told me otherwise." 

In that article, her research on the annual 33,000+ gun deaths in America, led her to several interesting observations and conclusions.  She writes, for example, that the statistics showed her:

  • "Two-thirds of gun deaths in the United States every year are suicides."
  • "Older men, who make up the largest share of gun suicides, need better access to people who could care for them and get help."

Libresco's essay sent me in turn to a feature story, part of a FiveThirtyEight series analyzing annual gun deaths, on "Surviving Suicide in Wyoming," by Anna Maria Barry-Jester.  She writes in greater detail about warning signs of deteriorating mental health, especially among older men: isolation, sometimes self-imposed; sleeplessness; depression; anxiety; and unresolved physical health problems. 

As these articles point out, limiting access to guns is appropriate for individuals with suicidal thoughts. That's different than "gun control laws."  And while guns may too often be the means to effectuate "rash desperate decisions," these researchers also suggest the greatest need is for better public awareness and response to warning signs, and for improved diagnosis and access to effective care, including social, mental and physical health care.    

October 6, 2017 in Advance Directives/End-of-Life, Crimes, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Science, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Thursday, August 31, 2017

The Eyes Have It? A New Tool To Detect Alzheimer's?

USA Today ran a story, Can this eye scan detect Alzheimer's years in advance? This short article explains that according to scientists "early indicators of Alzheimer's disease exist within our eyes, meaning a non-invasive eye scan could tip us off to Alzheimer's years before symptoms occur... It turns out the disease affects the retina — the back of the eye — similarly to how it affects the brain, notes neuroscience investigators at Cedars-Sinai Medical Center in California. Through a high-definition eye scan, the researchers found they could see buildup of toxic proteins, which are indicative of Alzheimer's." The study on which this article is based was published in the Journal of Clinic Investigation.  Retinal amyloid pathology and proof-of-concept imaging trial in Alzheimer’s disease is downloadable as a pdf by clicking here. The 19 page article offers this intriguing statement. "Such retinal amyloid imaging technology, capable of detecting discrete deposits at high resolution in the CNS, may present a sensitive yet inexpensive tool for screening populations at risk for AD, assessing disease progression, and monitoring response to therapy." (Warning-there are a lot of detailed photos of eyes in this article).

 

August 31, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Other, Science | Permalink | Comments (0)

Tuesday, August 1, 2017

On Finding Balance in Relationships (and Technology) As One Ages

Over the weekend, I caught an interesting episode of "On Being," with public radio host Krista Tippett.  While the nominal topic was "the good, bad and the  ugly" of the internet, and especially of internet-based social media sites, I found the conversation with her guest relevant on a number of levels, including questions about the importance of healthy relationships and intellectual stimulation for individuals as they age.

The guest speaker, Danah Boyd, a researcher, book author and pro-technology blogger, especially internet technology, talked about concerns that many parents may have, that their children are negatively affected by the amount of time they spend on the internet, whether in the form of Facebook, emails, chatrooms or simply surfing.  "Why don't they just go outside and play together like we did as children, especially in the summer?"

In response, Boyd pointed out that there is a "tremendous amount of fearmongering that emerged in light of 24/7 news...."  She continued:

We created this concern that public spaces like the park were a terrible, terrible place.  We were worried about latchkey children.  We were worried about school buses.  We clamped down on young people, and we started, especially in middle to upper class environments, structuring every day of their lives.

She drew upon examples, including some from Eric Klinenberg, a sociologist who wrote Going Solo to examine the implications of living a "single life," to suggest a possible explanation for young people retreating into the internet is the need to escape the pressures of overly structured daily lives.  

If true, wouldn't the need to escape increase as you get older and encounter more pressure to work, be on time, succeed, and to multi-task?  The need to detach from one-on-one relationships might be greater.

While the program did not talk directly about the upper ages of such a trajectory, as I listened to the program I couldn't help but think there is some greater truth here.  I see some people continue to want to stay engaged in one-on-one social relationships as they move into the "older" of older ages, but I also see many, including some of my own family members, do the exact opposite.  No, they aren't retreating into the internet, but they are retreating from what they might see as pressures to communicate, to be articulate, to "chat" with long time friends or family members. Perhaps for some it is the television, rather than a cell phone or iPad that serves as the protective shield.  

But, for future generations of elders will the internet still be intriguing and continue to offer escape routes?

One of the things that I liked about the "On Being" discussion was the discussion of the importance of striving for balance in the midst of technological changes.  Boyd said:

From my perspective, it’s about stepping back and not assuming that just the technology is transformative, and saying, okay, what are we trying to achieve here? What does balance look like? What does happiness look like? What does success look like? What are these core tenets or values that we’re aiming for, and how do we achieve them holistically across our lives? And certainly, when parents are navigating this, I think one of the difficulties is to recognize that this is what your values are, and they may be different from your child’s values. And so how do you learn to sit and have a conversation of “Here’s what I want for you. What do you want? And how do we balance that?” And that’s that negotiation that’s really hard. And so I think about it in terms of all of us — how do you find your own sense of grounding?

She concludes, suggesting internet technology is an important tool for making connections and having relationships, but "reflection" about life goals is also important.  Or as Boyd says, "There are so many opportunities out there to connect, to communicate, to get information. We need to be more thoughtful about what we want to achieve and how to articulate that in our lives and how to achieve it collectively, individually, and as a community."

August 1, 2017 in Books, Ethical Issues, Science, Web/Tech | Permalink | Comments (0)

Friday, July 28, 2017

Ted Talk: Can Alzheimer's Disease be Prevented?

Neuroscientist Lisa Genova PhD, author of the novel Still Alice (that, in turn, became the movie with Julianne Moore in the leading role), has an encouraging new piece on Ted Talk on what all of us can and should do now to reduce the risk of Alzheimer's or even slow the disease after diagnosis. As she says, "DNA alone does not determine whether you will be symptomatic for Alzheimer's."  It is one of a multi-part feature on Ted Talk addressing various "Prevention" topics.  Here's and NPR link to the 14 minute podcast for Lisa's piece,  "What You Can Do to Prevent Alzheimer's?"

Correction:  My thanks to the readers who caught my typo -- it's "Still Alice," not Still Alive, for the title to the book and movie I've linked here!

 

July 28, 2017 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Science | Permalink | Comments (1)

Wednesday, July 26, 2017

Dementia Prospects Down?

Good news for all of us!  The July 2017 issue of Today's Research on Aging from the Population Reference Bureau reports a proportional decline in dementia. Dementia Trends: Implications for an Aging America explains that

While the absolute number of older Americans with dementia is increasing, the proportion of the population with dementia may have fallen over the past 25 years, according to a recent U.S. study (Langa et al. 2017). Researchers say this downward trend may be the result of better brain health—possibly related to higher levels of education and more aggressive treatment of cardiovascular risk factors such as high blood pressure and diabetes.

After discussing the research, the research report also notes this

The decline in dementia prevalence coupled with longer life expectancy may be contributing to another change: A growing share of older Americans are spending less of their lifetimes with cognitive impairments, another recent study based on HRS data and vital statistics shows (Crimmins, Saito, and Kim 2016). The gains in life expectancy between 2000 and 2010 represent more time older Americans spend cognitively intact, the researchers report. The share of Americans 65 and older without cognitive problems increased by 4.5 percentage points for men and 3.4 percentage points for women during the decade. At the same time, the average time older people spent with dementia or cognitive impairment shortened slightly.

The report discusses the various theories and work done to help  with "brain training", the correlations (if any) between certain diseases and dementia, and policy and budgetary implications. The report concludes:

Improvements in understanding, diagnosing, preventing, and treating Alzheimer’s disease and other dementias are top NIA priorities. The 2011 National Alzheimer’s Project Act and related legislation lay the foundation and provide new funding for “an aggressive and coordinated national plan to accelerate research.” This initiative includes research designed to better answer the following questions:

•What roles do education and intellectual stimulation play in delaying or preventing dementia?

•What are the connections among dementia, cardiovascular disease, obesity, and diabetes?

•What are the best ways to reduce the dementia risks that minority group members face?

Refining our understanding of the answers to these questions can enable policymakers and

planners to design and test prevention strategies that can contribute to continued future decline

in dementia prevalence.

 

July 26, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Science, Statistics | Permalink | Comments (0)

Monday, May 22, 2017

NAELA Chapter Joins as Amicus for New York Aid in Dying Case

In what is described as a "first" for the National Academy of Elder Law Attorneys (NAELA), the organization through its New York Chapter will present argument on behalf of individuals seeking to establish access to "aid in dying."  On April 27, the New York Chapter was granted leave to appear as amicus curiae in Myers v. Schneiderman before the New York Court of Appeals.  Oral arguments are scheduled in Albany on May 30, 2017.

At issue is New York's penal law prohibiting assistance in "suicides."  The original suit, filed in February 2015, sought a ruling that the statute, characterized by opponents as "antiquated," should be interpreted as not reaching the conduct of a physician that provides aid-in-dying where the patient is terminally ill and mentally competent and voluntarily seeks "terminal medication."  Alternatively, the opponents of the law argue that the statute violates the rights of privacy and/or equal protection guaranteed by the New York State Constitution. New York's trial level court dismissed the challenge as a matter of law, on the grounds that New York's penal law was "clear on its face."  

In joining the challenge to the dismissal, which was affirmed by  appellate division, New York NAELA wrote:

As an organization of lawyers who represent the elderly and persons with disabilities, the New York Chapter [of NAELA] believes that a proper interpretation of New York's "assisted suicide" laws and due consideration of Appellants' constitutional challenges should be based on a fully developed factual record.  These are issues of great moment to the elderly and those who love them and to the administration of justice in this State.  This Court should have the benefit of a hearing and findings of relevant evidence before deciding them. . . .

What would assist this Court in fairly construing the Penal Law are facts relating to aid-in-dying.  While the language of the statute is the starting point for interpretation, its words do not exist in a vacuum.   

For more on the arguments, including links to the various parties' appellate briefs in Myers, see the "End of Life Liberty Project."

 

May 22, 2017 in Advance Directives/End-of-Life, Cognitive Impairment, Discrimination, Ethical Issues, Health Care/Long Term Care, Science, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Thursday, April 20, 2017

94 Year Old Genius

The New York Times ran an article earlier this month about a 94 year old genius. To Be a Genius, Think Like a 94-Year-Old features Dr. John Goodenough. who "at 94, has just set the tech industry abuzz with his blazing creativity. He and his team at the University of Texas at Austin filed a patent application on a new kind of battery that, if it works as promised, would be so cheap, lightweight and safe that it would revolutionize electric cars and kill off petroleum-fueled vehicles." Back when Dr. Goodenough was 23 and starting college, he was told by a professor that he was too old to succeed in his chosen field of physics.  The article mentions how for some creativity increases with age but there are biases and hurdles in their way.

At least in Silicon Valley, the article notes, youth seems to be the common denominator. But, for others "there’s plenty of evidence to suggest that late blooming is no anomaly. A 2016 Information Technology and Innovation Foundation study found that inventors peak in their late 40s and tend to be highly productive in the last half of their careers." Even someone from the Patent Office has noticed that “there’s clear evidence that people with seniority are making important contributions to invention.”

The author asks Dr. Goodenough for his thoughts.

When I asked him about his late-life success, he said: “Some of us are turtles; we crawl and struggle along, and we haven’t maybe figured it out by the time we’re 30. But the turtles have to keep on walking.” This crawl through life can be advantageous, he pointed out, particularly if you meander around through different fields, picking up clues as you go along. Dr. Goodenough started in physics and hopped sideways into chemistry and materials science, while also keeping his eye on the social and political trends that could drive a green economy. “You have to draw on a fair amount of experience in order to be able to put ideas together,” he said.

Plus being a 94 year old scientist is freeing. "Last but not least, he credited old age with bringing him a new kind of intellectual freedom. At 94, he said, 'You no longer worry about keeping your job.'"

April 20, 2017 in Consumer Information, Current Affairs, Other, Science | Permalink | Comments (0)