Wednesday, August 1, 2018
How do you find participants for clinical drug trials, especially if related to the dreaded "A" word, Alzheimer's disease? As outlined in The New York Times, such recruitment is not easy.
There are 5.4 million Alzheimer’s patients in the United States. You’d think it would be easy to find that many participants for a trial like this one. But it’s not. And the problem has enormous implications for treatment of a disease that terrifies older Americans and has strained families in numbers too great to count.
The Global Alzheimer’s Platform Foundation, which is helping recruit participants for the Lilly trial, estimates that to begin finding participants, it will have to inform 15,000 to 18,000 people in the right age groups about the effort. Of these, nearly 2,000 must pass the initial screening to be selected for further tests to see if they qualify.
Just 20 percent will meet the criteria to enroll in Lilly’s trial: They must be aged 60 to 89, have mild but progressive memory loss for at least six months, and have two types of brain scans showing Alzheimer’s is underway. Yet an 80 percent screening failure rate is typical for Alzheimer’s trials, said John Dwyer, president of the foundation. There is just no good way to quickly diagnose the disease.
The onerous process of locating just 375 patients illustrates a grim truth: finding patients on whom to test new Alzheimer’s treatments is becoming an insurmountable obstacle — no matter how promising the trial.
For more, read, For Scientists Race to Cure Alzheimer's, the Math is Getting Ugly. My thanks to colleague Laurel Terry for passing this article on to us.
Friday, July 27, 2018
I've learned to be skeptical about reports on new medications for Alzheimer's dementia. The reports from drug companies come and go, often fading into obscurity.
Nonetheless, results of a large clinical trial as reported at the Alzheimer's Association International Conference in Chicago this week seem to offer more promise. From the New York Times' article:
The trial involved 856 patients from the United States, Europe and Japan with early symptoms of cognitive decline. They were diagnosed with either mild cognitive impairment or mild Alzheimer’s dementia, and all had significant accumulations of the amyloid protein that clumps into plaques in people with the disease, said Dr. Lynn Kramer, chief medical officer of Eisai, a Japan-based company that developed the drug, known as BAN2401, along with Biogen, based in Cambridge, Mass.
Many other drugs have managed to reduce amyloid levels but they did not ease memory decline or other cognitive difficulties. In the data presented Wednesday, the highest of the five doses of the new drug — an injection every two weeks of 10 milligrams per kilogram of a patient’s weight — both reduced amyloid levels and slowed cognitive decline when compared to patients who received placebo.
Of the 161 patients in the group taking the highest dose, 81 percent showed such significant drops in amyloid levels that they “converted from amyloid positive to amyloid negative,” Dr. Kramer said in an interview, meaning that the patients’ amyloid levels dropped from being considered high enough to correlate to dementia to a level below that dementia threshold.
The results discussed above apparently arise out of Phase II of the drug's testing. An earlier report, in 2017, was more equivocal, as captured on the ALZforum website here.
Further, as reported on Endpoints News, an "independent news organization reporting and analyzing the top global biotech and pharmaceutical R & D News of the day," a critical response is emerging since this week's public announcement:
But instead of cheering on evidence of success [for BAN2401], a large group of analysts last night zeroed in on a crucial change in the study that could have confounded the data presented — and now we have a brand new controversy to add to the literature of Alzheimer’s.
For more of the critique, read Eisai, Biogen Battered by Controversy over PhII Alzheimer's Study After Posting Positive Results.
Monday, July 16, 2018
The National Academies Press has released Future Directions for the Demography of Aging.This volume contains the proceedings of a workshop and the overview explains
Almost 25 years have passed since the Demography of Aging (1994) was published by the National Research Council. Future Directions for the Demography of Aging is, in many ways, the successor to that original volume. The Division of Behavioral and Social Research at the National Institute on Aging (NIA) asked the National Academies of Sciences, Engineering, and Medicine to produce an authoritative guide to new directions in demography of aging. The papers published in this report were originally presented and discussed at a public workshop held in Washington, D.C., August 17-18, 2017.
The workshop discussion made evident that major new advances had been made in the last two decades, but also that new trends and research directions have emerged that call for innovative conceptual, design, and measurement approaches. The report reviews these recent trends and also discusses future directions for research on a range of topics that are central to current research in the demography of aging. Looking back over the past two decades of demography of aging research shows remarkable advances in our understanding of the health and well-being of the older population. Equally exciting is that this report sets the stage for the next two decades of innovative research–a period of rapid growth in the older American population.
Part 1 looks at trends in health and health disparities, Part 2 examines the implications of social and environmental factors, Part 3 covers families and intergenerational issues, Part 4 covers employment and retirement, Part 5 discusses cognitive issues and disability, Part 6 reviews global aging and Part 7 offers new approaches. You can purchase the softcover book here, download a free pdf of the book by clicking here or read the book online.
Friday, May 25, 2018
Of course, I'm supposed to be finishing my exam grading. Instead, while stopping by my office, I find a copy of a short story from one of my colleagues. The accompanying note says,"Not even my sci-fi 'escape' is untouched by elder care issues. Thought you'd get a kick out of this."
And indeed, I do. I definitely recommend "Today I Am Paul," by Martin L. Shoemaker. The author draws upon his personal experiences in visiting his mother-in-law in a nursing home to craft a true tale ... with a difference ... as the narrating caregiver is an android.
While my printed-page-loving self recommends reading the short story, I also found a great podcast of the story being read aloud by Kate Baker and I'm linking it here, from Clarkesworld Magazine.
I now plan to use this story to introduce my Elder Law course in the autumn. So much to talk about, including the roles of family, caregivers, technology, fear..... I suspect my co-blogger Becky Morgan, with her often expressed enthusiasm for tech including driverless cars, will appreciate this story too. Happy reading or listening for Memorial Day weekend!
Many thanks to Dickinson Law Professor Matthew Lawrence for this unique, caring experience.
Monday, May 21, 2018
Lisa Stegall, Assistant Professor of Biology at Hamline University, reports on positive results from a study where adults aged 60 to 80 participated in a weekly program of simple dance moves. From her report for Academic Minute:
Once a week for nine weeks, seniors aged 60 to 80 years old participated in an hour of music and movement training called Dalcroze eurhythmics. Led by a certified instructor who played improvised music on a piano, the seniors walked in time with the music, changed directions, and handled and passed objects rhythmically. They moved individually, with a partner, and in small groups to increase social interaction.
Our research team, made up of faculty and students from the Exercise Science, Music, and Public Health programs, tested the participants’ walking ability before and after the intervention, and found that gait (or walking) speed significantly improved. This held true even when participants were asked to walk and perform another task at the same time, called dual tasking. This latter finding is important because most falls occur while walking, especially when also performing other tasks.
Why did this intervention improve dual-task walking speed by 20%? We hypothesize that the improvement was due to the multicomponent movement training that’s unique to Dalcroze eurhythmics. Stepping to the beat of the music while carrying a ball, and passing that ball to another person in time with the music requires awareness, attention, balance, and coordination. These are the same skills needed when navigating the home, neighborhood, or the grocery store.
I expect we will see Dalcroze Eurhythmics classes coming soon to a gym or dance studio near you! My thanks to Dickinson Law colleague Laurel Terry for this tip.
Thursday, May 17, 2018
We all can sing along to that fabulous Beatles song, When I'm 64. Perhaps the Beatles were prescient, as now Kaiser Health News has published an article about remaining relevant in your life when you are 64 and beyond.... Will We Still Be Relevant ‘When We’re 64’? opens with this description
A gnawing sense of irrelevancy and invisibility suddenly hits many aging adults, as their life roles shift from hands-on parent to empty nester or from workaholic to retiree. Self-worth and identity may suffer as that feeling that you matter starts to fade. Older adults see it in the workplace when younger colleagues seem uninterested in their feedback. Those who just retired might feel a bit unproductive.
The article then segues into a discussion of various recent studies that bears out this fear of becoming irrelevant. Whether it's being important at work or important in your personal life, there is a value to being relevant, or even being needed, even if it's just giving advice to a younger person. "Having purpose and meaning forestalls loneliness, which takes an emotional and physical toll. Studies by ... researchers have found that loneliness is associated with weaker immune systems and poorer physical health."
One group in Austin, Texas (the slogan, "Keep Austin Weird") took initiative by "finding their purpose with a community created by Aging is Cool, an active-aging company founded just over a year ago." The article discusses this community initiative as well as some other ones across the country, volunteering and continued employment. The article closes with an example for all of us: "96-year-old actress Betty White ... [who] still produces good work and she has a great amount of energy... Her entire package promotes a youthful and optimistic attitude.”
Monday, April 30, 2018
I'm always interested in articles about the use -- misuse? -- of antipsychotic medications for older adults. Therefore I was eager to read the recent post on the Health Affairs Blog by David Introcaso entitled The Never-Ending Misuse of Antipscyhotics in Nursing Homes. The article begins:
In response to a generic question about post-market drug surveillance posed during a February 2007 House Energy and Commerce Committee hearing, Dr. David Graham, then associate director of science and medicine in the Food and Drug Administration’s (FDA’s) Office of Surveillance and Epidemiology, stated: “I would pay careful attention to antipsychotic medications. … The problem with these drugs are that we know that they are being used extensively off label in nursing homes to sedate elderly patients with dementia … . It is known that the drugs don’t work in those settings. … But the fact is, is that it increases mortality perhaps by 100 percent. It doubles mortality. So I did a back-of-the-envelope calculation on this and you probably got 15,000 elderly people in nursing homes dying each year from the off-label use of antipsychotic medications for an indication that FDA knows the drug doesn’t work. This problem has been known to FDA for years and years and years.”
I've highlighted in bold the words that are the focus of my interest: "It is known that the [antipsychotic] drugs don't work in those settings." No citation to authority here - and it is the authority for this statement that I would like to see. Is there a study of the use of antipsychotic drugs showing they "don't work" for dementia patients? What does it mean "not" to work? Is all "use" a "misuse" for patients who "only" have dementia?
I ask because I saw my father struggle at home for several years with dementia. As the disease robbed him of the ability to understand where he was and why he couldn't remember things, he sometimes became aggressive. He was still very strong. His doctor tried various mild anti-anxiety drugs, but they seemed to interact with his blood pressure issues (and perhaps his other medications). He would sometimes swing between aggressive behavior and losing consciousness. Finally his doctor suggested a very small dose of an antipsychotic. My mother was desperate for help at the time -- and thus, Dad started on the drug. This is an example of "off label" use. I was worried, and said so, because I knew the associated concerns about increased mortality for those with dementia. I looked for specific studies of risk versus benefit and frankly, all I could find were records showing the ratio of deaths for individuals with dementia who also were taking an antipsychotic drug. Mere correlation is not necessarily evidence of causation. What I was looking for was a careful study of risk versus benefit.
Over time I saw that the small dose did "work" for this one individual, my father. He wasn't "knocked out." He wasn't "docile." He wasn't "asleep all the time" -- typical of the accusations that are often made about misuse of antipsychotics. What we did see was that he was much less likely to strike out an arm or push someone hard when he was frustrated (and yes, he was still frustrated). The small dose did not interfere with his blood pressure or the other medications he was taking. Perhaps most importantly, he continued to live at home for many more months. Eventually it was appropriate to wean him off the antipsychotic altogether.
One anecdotal account is not evidence. But the fact that there reportedly continues to be "widespread"use of antipsychotic drugs by the elderly means there could be some very real need for safe, effective alternatives. Behavioral health approaches are important, but those too can have limits in effectiveness. I'd certainly like there to be "good" studies of the use of these drugs and any drug that might be able to help a person suffering from dementia live a less tormented life. Not zoned out and not asleep all the time, but also not likely to harm themselves or those who on a daily basis are trying to help them live as normally as possible.
Monday, April 23, 2018
You've heard the phrases such as "60 is the new 40." Now we learn there may be some truth to the thought that you feel younger than your chronological age.The Washington Post recently published this article, Cliches about only being as old as you feel are starting to have scientific backing.
The article focuses on research that indicates many folks who are older feel good about themselves and about the negative messages about aging that affect us all. The article references "[o]ne study ... [that] found that as people get older, they consistently say they feel younger — much younger — than their actual age. Another study examining the attitudes of the offspring of centenarians concluded that the centenarians’ children — if they, too, were healthy and long-lived — have a strong sense of purpose and meaning to their lives, compared with the general population. Finally, there is evidence that positive attitudes about aging may reduce the risk of dementia, among the most dreaded consequences of aging." Yet, we start being bombarded with negative messages about aging at a very young age. One expert noted that kids even age 3 or 4 already have absorbed "the age stereotypes of their culture,” which it seems come from "many sources, ranging from stories to social media. Individuals of all ages can benefit from bolstering their positive images of aging.” Another expert quoted in the article explains that “[n]egative views about aging are communicated to us early in life, through media, books and movies, and what our friends and family tell us... [and that such] attitudes are present and pervasive already in childhood, so naturally it’s hard to enact meaningful change to these attitudes....”
Several studies are referenced in the article. The studies bear out the idea that folks who are older feel younger than their chronological ages, but as far as younger people's perceptions, they consider old to be a lower number than those who are old would offer. For example, one researcher offered that "teenagers and young adults equated turning 50 with hitting old age."
And we've all heard the saying about attitude is everything. It turns out those with positive views of aging help with reducing stress and decreasing chances of dementia. One research summarizes her findings: She "evaluated 4,765 older people — average age, 72 — who were free of dementia at the start of the study and followed them for four years. The participants answered a series of questions about their beliefs about aging [and the researchers] found [that] those who expressed more-positive age beliefs at baseline were less likely to develop dementia . . . than those who expressed more-negative age beliefs...."
So remember, the class is half-full and aging is not a bad thing!
Friday, April 20, 2018
Recently the Washington Post published an article comparing generational alcohol intake. Teenagers and college-age people drink less while this group pours another round opens with this observation "[e]xperts on alcohol abuse have found one demographic group that’s drinking at an alarming rate. Not teenagers. Not college-age people. It’s baby boomers." The first few paragraphs of the article focus on younger individuals and then turns to Boomers, noting that it's "been known for half a century is that baby boomers tend to like alcohol more than the “silent generation” that preceded them."
"Researchers see a steady rise in alcohol use and binge drinking — as well as what’s known as Alcohol Use Disorder (AUD), an umbrella term for mild, moderate and severe abuse of alcohol — in the 65-plus demographic. Between 2005 and 2014, the percentage of older Americans who reported engaging in past-month binge drinking (defined as women consuming four or more drinks in about two hours, and men consuming five or more) increased from 12.5 percent to 14.9 percent ... [and] [t]he increase in drinking among older Americans is most pronounced among people with greater levels of education and income, and among women.... At continuing care communities, alcohol is typically available as a social lubricant for the majority of residents who haven't graduated to assisted living...."
according to one expert quoted in the article.
One thing that is implicated in this is the perception or impression that moderate alcohol consumption is healthy. "[M]any boomers have embraced the notion that moderate drinking is good for them, compared to abstaining. The evidence there is mixed. A number of studies have shown a reduction in heart attacks among moderate drinkers. But a new study published in the Lancet last week showed no overall improvement in life expectancy among people who had one drink a day compared to those who abstained, and a decrease in life expectancy with any additional drinking. The study's authors concluded that the reduction in heart attacks was offset by other health risks."
Wednesday, April 11, 2018
The Alzheimer's Association has released their annual facts and figures report. 2018 Alzheimer's Disease Facts & Figures also includes a special report on the benefits (personal and financial) of early diagnosis. Here are some highlights of topics covered in the report:
Brain changes that occur with Alzheimer’s disease …
Revised guidelines for diagnosing Alzheimer’s disease …
Number of Americans with Alzheimer’s dementia nationally … and for each state …
Proportion of women and men with Alzheimer’s and other dementias …
Lifetime risk for developing Alzheimer’s dementia …
Number of deaths due to Alzheimer’s disease nationally … and for each state … and death rates by age …
Number of family caregivers, hours of care provided, and economic value of unpaid care nationally and for each state …
The impact of caregiving on caregivers …
National cost of care for individuals with Alzheimer’s or other dementias, including costs paid by Medicare and Medicaid and costs paid out of pocket …
Medicare payments for people with dementia compared with people without dementia
Benefits of earlier detection of Alzheimer's disease …
Cost savings of diagnosing during the earlier mild cognitive impairment stage rather than the dementia stage …
There is a lot of helpful information and statistics in the report. The chart showing the numbers of those with Alzheimer's in 2018 compared to the projections for 2025 is very useful. (Just fyi, my state is expected to have a 33.3% increase). Consider this from page 21 of the report:
“[B]etween 2018 and 2025 every state across the country is expected to experience an increase of at least 13 percent in the number of people with Alzheimer’s. These projected increases in the number of people with Alzheimer’s are due to projected increases in the population age 65 and older in these states. The West and Southeast are expected to experience the largest percentage increases in people with Alzheimer’s between 2018 and 2025. These increases will have a marked impact on states’ health care systems, as well as the Medicaid program, which covers the costs of long-term care and support for some older residents with dementia.”
Tuesday, April 10, 2018
According to the New York Times, late last month, the House of Representatives passed the right to try bill on their second attempt. House Passes Bill That Would Give Patients Access to Experimental Drugs explains that "[s]upporters said the bill would give dying patients a chance to obtain potentially helpful prescription drugs without waiting for the completion of clinical trials or going through a process established by the Food and Drug Administration to allow the use of “investigational drugs” outside clinical trials." There were supporters as well as opponents of the bill.
The House and Senate bills would establish a new pathway providing access to unapproved medicines for certain patients who had exhausted other treatment options. To qualify under the House bill, a patient would have to have some kind of terminal illness: a condition that is likely to cause death “within a matter of months” or “irreversible morbidity that is likely to lead to severely premature death.”
Nothing in the bill would require pharmaceutical companies to provide experimental drugs to patients who requested them. Drug manufacturers sometimes turn down requests because they have only a limited supply or they are concerned about legal and medical risks.]
To address such concerns, the legislation would shield drugmakers, doctors and hospitals from some of the legal risks of providing unapproved drugs to patients. Doctors and hospitals would generally be protected unless they engaged in gross negligence or willful, reckless or criminal misconduct.
Thursday, March 29, 2018
Penn State's Dickinson Law Hosts Pennsylvania Judges for Program on "Dementia Diagnosis and the Law"
On Thursday, March 29, 2018 Penn State's Dickinson Law hosted a continuing judicial education program for the Pennsylvania Judiciary, with live attendance in Carlisle by more than 30 judges and with even more judges around the state participating via a live stream. The program was "Dementia Diagnosis and the Law," organized into three parts:
Part 1: Medical Science and Dementia
- Welcome by Dean Gary Gildin, Dickinson Law
- Keynote Presentation: Age-Related Cognitive Decline
- Krish Sathian, M.D., Ph.D., Professor of Neurology and Chair of the Department of Neurology for Penn State College of Medicine and Penn State Health Milton S. Hershey Medical Center
- Medical Perspectives – Responding to Legal and Ethical Quandaries of a Diagnosis: Two Brief Vignettes
- Associate Professor Claire Flaherty, Ph.D., Penn State College of Medicine, Department of Neurology
Panel Discussion and Audience Q & A
Part 2: Legal Implications of a Diagnosis of Dementia
- Keynote Presentation: Clinical, Legal and Judicial Judgments of Capacity in Persons with Dementia
- Daniel C. Marson, Ph.D., JD., Professor Emeritus, Department of Neurology, School of Medicine, University of Alabama at Birmingham
- Why “Guardianship Oversight” is a Hot National (and State) Topic
- Professor Katherine C. Pearson, Dickinson Law, Pennsylvania State University
Panel Discussion and Audience Q & A
Part 3: Adjudication Exercises, facilitated by Professor Tiffany Jeffers, Dickinson Law, with Dickinson Law students in role plays on issues about capacity to contract, limited guardians, the roles of guardians ad litem and the potential for attorneys or judges to become affected by a neurocognitive disorder.
- Panel Discussion and Audience Q & A
Panel Members included:
- The Honorable Lois Murphy, Judge, Montgomery County Court of Common Pleas
- The Honorable Paula Ott, Judge Superior Court of Pennsylvania
- Sally L. Schoffstall, Schoffstall Elder Law LLC, Orefield, PA.
- Laurel S. Terry, H. Laddie Montague Jr. Chair in Law & Professor of Law, Penn State’s Dickinson Law
As the law school's organizer for the event, I know I learned a lot from this dynamic group of seasoned experts who spoke on the challenging legal, medical, and judicial issues that can arise from cognitive impairments associated with aging. The judges in our audiences were fully engaged, offering great comments, questions and experiences.
My special thanks to each and every one of the speakers, facilitators, judges, lawyers and students who made the program so informative. It was fun to work with the Administrative Office of the Pennsylvania Courts on this project and we look forward to additional opportunities to collaborate in the future. Once I catch up a little on my day job (and maybe on some missed sleep), I'll post again with some additional reactions and thoughts from this program.
March 29, 2018 in Cognitive Impairment, Crimes, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Health Care/Long Term Care, Housing, Legal Practice/Practice Management, Property Management, Science | Permalink | Comments (1)
Tuesday, March 27, 2018
The Hidden Brain is a great radio program with frequent stories relevant to aging. A recent episode is titled Guys, We Have A Problem: How American Masculinity Creates Lonely Men. Frankly, I think the title doesn't do the episode justice, as although the episode focuses primarily on the potentially disproportionate likelihood of isolation and loneliness for men as they get older, many of the program's most important points strike me as applying equally to anyone who finds his or her life becoming more isolated.
One interview explored the moving personal history of a lawyer, Paul Kugelman, as he went through life, starting with disconnections connected to frequent military-service-connected family relocation, followed by his own divorce and struggles with work/life balance, a temptation to drink, and a a recovery strategy that included completing an Iron-Man Marathon. But running wasn't enough. Over-reliance on a spouse put enormous pressure on the relationship. He had to learn new skills to create new friendships.
The program also explored findings from an early Harvard study of American men, now known as the Harvard Study of Adult Development, a study that has been on-going, with various adjustments based on funding sources, for 8 decades. One question asked over the entire course of the study's history was deceptively simple:
Who would you call in the middle of the night if you were sick or afraid?
It turns out that if men had a solid answer to that question, they were happier with their lives and their marriages. "There were also connections with the men's answers to that question and their physical health. Very strong connections."
The program dug deeper into physical health and emotional connections, suggesting that we should think about how coming into work on a Monday morning. Do you look forward to seeing people you like? That connection is energizing. And calming.
The program explained that studies show that the people who are "happiest in retirement are those who actively work to replace colleagues with friends." "Spending time building and nurturing your friendships might be just as important to your health as eating right and exercising."
Bottom line: Don't miss the warning signs that your social circles are shrinking, regardless of gender.
Monday, February 12, 2018
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.
Monday, January 22, 2018
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.
Wednesday, January 17, 2018
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
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.
Monday, January 8, 2018
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
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.
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.
Wednesday, December 13, 2017
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.
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)