Wednesday, October 11, 2017
During the last several years, I've received calls from around the country about possible guardianship "oversight" concerns. And since The New Yorker article came out last week focusing on guardianship issues in Las Vegas Nevada, I've been getting more calls. The question arises: Is there a pervasive problem with court-appointed guardians for older adults in the United States?
In my opinion, the answer is "no, not pervasive." At least, that's my answer if the definition of pervasive is "universal," or omnipresent, or rife, or widespread. In the 20+ years I've been working in elder law, I've unfortunately reviewed a lot of cases of exploitation, but it is comparatively rare that I've been asked to examine a court-monitored guardianship where there was a problem created by inadequate attention by the courts, much less active misconduct by the court or agency. Granted, that is just one law professor's experience.
Still, in my opinion, the oversight problems that do exist within the U.S. are significant, periodic, sometimes recurring or persistent, and often have common elements. The issues can exist in any county court or fiduciary administrative system. Historically, these courts -- sometimes called probate courts, fiduciary courts, surrogate courts, or orphans courts -- depended on the guardians for management of all issues, once the appointments were made. The judges trusted their appointees to take their fiduciary responsibilities seriously. But, as is sometimes said in international relations, the problem can be how best to "trust, but verify" proper behavior. With more elder boomers, there can be increased need for guardians, and thus more potential for guardians to be monitored.
- For example, in Maricopa County, Arizona, an investigative news series, that began in 2008 with the reporting of Laurie Roberts for the Arizona Republic, described a number of mishandled older adult guardianships. In some instances, the family members were so busy arguing about money, that the incapacitated elder was ignored, while his or her estate was diminished to pay fees. Sometimes the question was whether a "full" guardianship was even necessary. The problems, once investigated not just by journalists but by the courts, resulted in changes in Arizona guardianship law.
- In Palm Beach County, Florida, complaints about appointment of a particular individual as guardian in a large number of cases, focused on conflict of interest and claims of favoritism by the court, complaints that came from a number of families. Eventually, in one case challenging the system, a jury reportedly awarded more than $16 million against two West Palm Beach attorneys for "breach of fiduciary duties." The complaints also led to state investigations of Florida's entire oversight systems, and brought three years of legislative changes to Florida guardianship laws.
- Most recently, two co-founders of a nonprofit guardianship company, Ayudando Guardianship, in Bernalillo County, New Mexico were indicted in federal court in July 2017 with criminal charges including conspiracy, mail fraud, aggravated identity theft, and money laundering. The company was the appointed fiduciary in hundreds of cases.
Especially when the Clark County, Nevada cases are included in this list of recent challenges to guardianship oversight systems, concerns about proper and objective oversight are real; without a equally real commitment to more careful selection, training, monitoring and accountability for guardians, the problems can be predicted to increase as the baby boomer generation of seniors get to their 70s, 80s, or 90s. In 2016, the GAO for the United States responded to a U.S. Senate Special Committee on Aging's request for data on "the extent of abuse by guardians," and concluded that "courts lack comprehensive data on older adults in guardianships and elder abuse by guardians, but some courts have limited information." Unreliable data certainly leaves open the potential for the occasional problems to become pervasive problems.
October 11, 2017 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, State Cases, State Statutes/Regulations, Statistics | Permalink | Comments (2)
Friday, October 6, 2017
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)
Wednesday, July 26, 2017
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.
Thursday, July 13, 2017
Here are some excerpts from the story about the study:
new measures of aging with probabilistic projections from the United Nations to scientifically illustrate that one’s actual age is not necessarily the best measure of human aging itself, but rather aging should be based on the number of years people are likely to live in a given country in the 21st Century.
The study also predicts an end to population aging in the U.S. and other countries before the end of the century. Population aging – when the median age rises in a country because of increasing life expectancy and lower fertility rates – is a concern for countries because of the perception that population aging leads to declining numbers of working age people and additional social burdens.
You'll recall the three cohorts of "old" 65-74, the "young old", 75-84, the old, and 85+ the old-old. According to this study, "[t]raditional population projections categorize “old age” as a simple cutoff at age 65. But as life expectancies have increased, so too have the years that people remain healthy, active, and productive. In the last decade, IIASA researchers have published a large body of research showing that the very boundary of “old age” should shift with changes in life expectancy, and have introduced new measures of aging that are based on population characteristics, giving a more comprehensive view of population aging."
The study focuses on the US, China, Iran and Germany. The study is available here.
Monday, July 10, 2017
The ABA Commission on Law & Aging and the Virginia Tech Center for Gerontology have released a report, Restoration of Rights in Adult Guardianship: Research & Recommendations. The report is divided into four parts: (1) introduction & background, (2) research on restoration of rights, (3) discussion & recommendations on key issues to restoration, and (4) conclusion. The report runs 69 pages and is available for download as a pdf. Section 3 covers a number of topics, including lack of knowledge of the availability of restoration, review by courts re: continuing need for guardianship, court access, attorney representation (and the attorney's role), the guardian's role, supports available to the person, evidence and evidentiary standards, and data and research. Here is the conclusion
The time is ripe for restoration of rights to be become a viable option for people subject to guardianship. In the context of the emergent paradigm of supported decision-making, restoration can be a path to self-determination and choice. For courts, attention to restoration can weed out unnecessary cases from dockets, allowing a stronger focus on problems needing judicial intervention, and saving administrative costs of carrying unnecessary cases.
To make restoration work:
• State legislation must ensure sufficient notice that the option exists, provide for regular court review of the continuing need for guardianship, afford the right to counsel, and set workable evidentiary standards.
• Courts must assess cases for possible restoration, find ways to make individuals and families more aware of the option, make the process more accessible, take into account available supports in making determinations, and track data on restoration.
• Guardians must perceive their role as enhancing self-determination and working toward termination of guardianship with sufficient support – more as "supporters" guided by the person’s expressed wishes if possible. There must be sufficient legal decision-making tools, family supports, technological supports, and community supports readily available to bolster functional abilities.
• Lawyers must recognize and act on the potential of restoration in guardianship cases.
This study has set the stage for such actions, bringing to life the possibility that guardianship is not automatically an end but can be "a way station and not a final destination."
July 10, 2017 in Cognitive Impairment, Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Health Care/Long Term Care, State Cases, State Statutes/Regulations, Statistics | Permalink | Comments (0)
Thursday, July 6, 2017
We have blogged on several occasions about the important role adult children play in family caregiving. Ever wonder just how much care the kids are providing? The Center for Retirement Research at Boston College looked at that specific question.
How Much Long-Term Care Do Adult Children Provide?, an issue brief, offered these key findings:
As people age and their health deteriorates, they begin to need more help with daily activities.
- While many formal long-term care services are available, cost concerns and personal preferences lead many to rely on informal care from adult children.
At any given point, 6 percent of adult children serve as caregivers, and 17 percent will take on this role at some point in their lives.
Those who do provide care devote an average of 77 hours per month, which can take a toll on both the finances and health of the caregiver.
The caregiving burden on adult children is likely to become a bigger concern as baby boomers move into their 80s.
Look again at the numbers. Seventeen percent of adult kids will be caregivers at some point and at almost 80 hours a month, it's almost like working half-time. Here is the conclusion to the brief:
At any point in time, few adult children are taking care of their parents. But, over the course of their lives, about 17 percent of adults end up providing care for their parents. And when children do care for par- ents, the commitment is large – 77 hours per month. As baby boomers enter their 80s, a large increase in the demand for long-term care is likely, with a commensurate rise in the reliance on care from their children. Since boomers had fewer children per household than the previous generation, this develop- ment will place an unprecedented burden on their children, with implications for their physical, mental, and nancial well-being. However, research also suggests that the issue may be more challenging than just the relative sizes of the generations. After all, divorced parents need more support from children, and those children are more likely to provide support if they live nearby. For a generation characterized by low fertility, unstable marriages, and far- ung children, this situation sug- gests that the informal care the boomers will need may not be there – and demand for formal care will soon increase beyond its historical levels. Policymakers and the private sector must confront this prospect, with its attendant burdens on the long-term care sector and insurers of long-term care – the largest of which by far is an already overburdened Medicaid system.
Consider the last sentence of the conclusion in light of the debated Congressional action on the Affordable Care Act.
The full brief is available here.
Friday, May 12, 2017
On May 10, 2017, my research colleagues Gavin Davidson (Queens University Belfast) and Subhajit Basu (University of Leeds) participated in a policy briefing at Stormont, the Northern Ireland Assembly in Belfast. They appeared in support of recommendations by the Commissioner of Older People (COPNI) Eddie Lynch on a major plan for modernization of social care programs for vulnerable adults (of any age).
Professors Davidson and Basu focused on three key recommendations:
- Northern Ireland should have a single legislative framework for adult social care with accompanying guidance for implementation. This could either be new or consolidated legislation, based on human rights principles, bringing existing social care law together into one coherent framework.
- All older people in Northern Ireland, once they reach the age of 75 years, should be offered a Support Visit by an appropriately trained professional. This will be based on principles of choice and self-determination and is aimed at helping older people to be aware of the support and preventative services that are available to them.
- Increasing demands for health and social care reinforce the importance of considering how these services should be funded. All future funding arrangements must be equitable and not discriminate against any group who may have higher levels of need.
The audience, which included researchers, social service program administrators and elected officials (not only from Northern Ireland, but elsewhere, including the Isle of Man), reportedly responded strongly to the recommendations, especially to the concept of specially-trained "support visitors," offered to persons age 75 or older. The intent is to provide individuals with planning support and, where needed, medical assessment. Guidance and information is often needed for pre-crisis planning, thus moving in the direction of prevention of crises and reduction of need for last-minute response. The support visitor concept has been used successfully in Denmark and other locations in Europe. The next step for Northern Ireland would likely be a pilot or test project.
As a co-author of the research reports that led to the COPNI recommendations, working with Professors Gavin Davidson and Subhajit Basu as part of a team headed by Dr. Joe Duffy of Queens University Belfast, I found it an interesting coincidence that at almost the same time as the Northern Ireland government session, I was addressing similar interests in "preventative" planning while speaking on elder abuse in a "Day on the Hill" program at the Capitol in Pennsylvania, hosted by the Alzheimer's Association. It is clear that on both sides of the Atlantic, we are interested in cost-effective, proactive measures to help people stay in their homes safely.
Wednesday, April 12, 2017
NAPSA and NCPEA have released a research to practice brief on Correlates of Depression in Self-Neglecting Older Adults: A Cross-Sectional Study Examining the Role of Alcohol Abuse & Pain in Increasing Vulnerability Here is the summary from this one page brief:
Older adults with confirmed self-neglect report high rates of depressive symptoms. It has been estimated that between 50-62% of older adults with confirmed self-neglect suffer from at least sub-clinical levels of depressive symptomatology. Depressive symptoms in this population have been linked to untreated medical conditions. Further study is needed to understand the association between elder self-neglect and depressive symptoms, including studies determining potential correlates of depression in this population. Identifying such correlates could inform clinical social work and other mental health approaches for reducing depressive symptoms and self-neglect behaviors in this population. The cur-rent cross-sectional study reviewed a host of self-reported cognitive, functional, demo-graphic and clinical measures and identified a positive history of alcohol abuse, low self-rated health and pain as significant correlates of depressive symptomatology in older adults with Adult Protective Services (APS) validated self-neglect. Those with a positive screen for prior alcohol abuse were approximately 3 times more likely to have at least sub-clinical depression (Geriatric Depression Scale-15 >4). Having lower self-rated health was associated with a 53% increase in the likelihood of reporting at least sub-clinical depression. Reporting pain was associated with a 37% increase in the likelihood of reporting at least sub-clinical depression. These findings did not allow for establishing a temporal direction between depression, history of alcohol abuse, low self-rated health or pain. Nevertheless, they do provide insight into possible targets for improving out-comes in elder self-neglect populations given their evidence-based associations with both depression and self-management activities including accessing healthcare and completing activities critical for safety and protection.
Thursday, March 23, 2017
- Over the past 10 years, the population 65 and over increased from 36.6 million in 2005 to 47.8 million in 2015 (a 30% increase) and is projected to more than double to 98 million in 2060.
- Between 2005 and 2015 the population age 60 and over increased 34% from 49.8 million to 66.8 million.
- The 85+ population is projected to triple from 6.3 million in 2015 to 14.6 million in 2040.
- Racial and ethnic minority populations have increased from 6.7 million in 2005 (18% of the older adult population) to 10.6 million in 2015 (22% of older adults) and are projected to increase to 21.1 million in 2030 (28% of older adults).
- The number of Americans aged 45-64 – who will reach 65 over the next two decades – increased by 14.9% between 2005 and 2015.
- About one in every seven, or 14.9%, of the population is an older American.
- Persons reaching age 65 have an average life expectancy of an additional 19.4 years (20.6 years for females and 18 years for males).
- There were 76,974 persons aged 100 or more in 2015 (0.2% of the total 65+ population).
- Older women outnumber older men at 26.7 million older women to 21.1 million older men.
- In 2015, 22% of persons 65+ were members of racial or ethnic minority populations--9% were African-Americans (not Hispanic), 4% were Asian or Pacific Islander (not Hispanic), 0.5% were Native American (not Hispanic), 0.1% were Native Hawaiian/Pacific Islander, (not Hispanic), and 0.7% of persons 65+ identified themselves as being of two or more races. Persons of Hispanic origin (who may be of any race) represented 8% of the older population.
- Older men were much more likely to be married than older women---70% of men, 45% of women. In 2016, 34% older women were widows.
- About 29% (13.6 million) of noninstitutionalized older persons live alone (9.3 million women, 4.3 million men).
- Almost half of older women (46%) age 75+ live alone.
- The median income of older persons in 2015 was $31,372 for males and $18,250 for females. Median money income (after adjusting for inflation) of all households headed by older people increased by 4.3% (which was statistically significant) between 2014 and 2015. Households containing families headed by persons 65+ reported a median income in 2015 of $57,360.
- The major sources of income as reported by older persons in 2014 were Social Security (reported by 84% of older persons), income from assets (reported by 62%), earnings (reported by 29%), private pensions (reported by 37%), and government employee pensions (reported by 16%).
- Social Security constituted 90% or more of the income received by 33% of beneficiaries in 2014 (21% of married couples and 43% of non-married beneficiaries).
- Over 4.2 million older adults (8.8%) were below the poverty level in 2015. This poverty rate is statistically different from the poverty rate in 2014 (10.0%). In 2011, the U.S. Census Bureau also released a new Supplemental Poverty Measure (SPM) which takes into account regional variations in living costs, non-cash benefits received, and non-discretionary expenditures but does not replace the official poverty measure. In 2015, the SPM shows a poverty level for older persons of 13.7% (almost 5 percentage points higher than the official rate of 8.8%). This increase is mainly due to including medical out-of-pocket expenses in the poverty calculations.
*Principal sources of data for the Profile are the U.S. Census Bureau, the National Center for Health Statistics, and the Bureau of Labor Statistics. The Profile incorporates the latest data available but not all items are updated on an annual basis.
Tuesday, January 24, 2017
Delirium and dementia are common causes of cognitive impairment in older populations. Although each may occur independently, delirium and dementia frequently coexist. Dementia is a leading risk factor for delirium, and there is an increased incidence of new dementia and cognitive decline after delirium. Delirium can accelerate the rate of cognitive decline, suggesting that an episode of delirium can result in a more rapid progression of dementia symptoms, leading to earlier functional disability, increased caregiver burden, and rising health care costs. As the population ages, there has been a rapid increase in the incidence and prevalence of delirium and dementia. Better understanding of the risk factors, outcomes, and mechanistic associations between these 2 conditions is therefore critical for developing successful prevention and treatment strategies for this increasing problem.
The conclusions and relevance from the article offers this:
CONCLUSIONS AND RELEVANCE Delirium in the presence of the pathologic processes of dementia is associated with accelerated cognitive decline beyond that expected for delirium or the pathologic process itself. These findings suggest that additional unmeasured pathologic processes specifically relate to delirium. Age-related cognitive decline has many contributors, and these findings at the population level support a role for delirium acting independently and multiplicatively to the pathologic processes of classic dementia.
A new one hour documentary, Alzheimer's: Every Minute Counts, is scheduled to begin airing nationally on PBS stations on Wednesday, January 25.
In part, the documentary will focus on research funding issues. Dr. Ruby Tanzi, a Harvard Medical School researcher who appears on the film, explained for NextAvenue's website:
We should be absolutely panicked at the government level. When the Medicare and Medicaid [treatment and care] bill for Alzheimer’s goes from one in five dollars to one in three dollars — that could happen over the next decade with baby boomers getting older — we could single-handedly collapse Medicare and Medicaid with Alzheimer’s disease.
Now, the government [research funding for Alzheimer's] has gone up to about a billion dollars. Which is great, it’s more money. It’s still not the billions of dollars that go to other age-related diseases. I’m glad that cancer and heart disease and AIDS get many billions of dollars, but Alzheimer’s has to get as much or more now given the epidemic and the urgency here with how many cases we’re going to have.
It’s going to crush us. Never mind the social burden on the families. I might add that two-thirds of patients are women. And most caregivers are women. What’s going to happen when so much of our female population is (struck) with this disease? So it’s a huge problem and if we don’t throw a ton of money at it now, it’ll be a disaster.
For more information on the documentary, including links to watch it on-line (free!), see PBS "Alzheimer's: Every Minute Counts." There is an important opportunity here for schools, including law schools, to host an airing of the documentary to promote discussion about strategies.
Sunday, January 22, 2017
University of Illinois Law Professor Richard Kaplan responded to my post last week, that questioned the appropriate age to compel IRA distributions, by providing a more in-depth look at the topic, via his own article, Reforming Taxation of Retirement Income.
His recommendations include simplifying how Social Security retirement benefits are taxed, bifurcating defined contribution plan withdrawals into capital gains and ordinary income components, repealing certain exceptions to the early distribution penalty, reducing the delayed distribution penalty and adjusting the age at which it is triggered, and changing the residential gain exclusion to avoid unanticipated problems with reverse mortgages.
The 2012 Virginia Tax Review article demonstrates that increased life expectancy supports an increase to age 74 (from 71.5) as the trigger for mandatory distributions.
Thanks, Dick! As always, you have important analysis to share.
Thursday, January 19, 2017
The New York Times has a recent article that resonates with me. I am spending my sabbatical time in Arizona in order to be of more help to my sister with our parents who are both in their 90s. Neither my sister or I have children and we sometimes question what will happen with us if we reach our parents' age with similar needs. Here's an excerpt from the piece that gets right to the point:
While the demand for caregivers is growing because of longer life expectancies and more complex medical care, the supply is shrinking, a result of declining marriage rates, smaller family sizes and greater geographic separation. In 2015, there were seven potential family caregivers for every person over 80. By 2030, this ratio is expected to be four-to-one, and by 2050, there will be fewer than three potential caregivers for every older American.
For more, read the thoughtful essay Who Will Care for the Caregivers? by Dr. Dhruv Khullar, a resident physician at Massachusetts General Hospital and Harvard Medical School.
Tuesday, January 17, 2017
With the new Presidential administration ahead, many of us are asking what government policies or programs will be "re-imagined." With changes on the horizon, an especially interesting perspective on long-term care is offered by UCLA Law Professor Allison Hoffman with her recent article, "Reimagining the Risk of Long-Term Care," published in the Yale Journal of Health Policy, Law & Ethics. From the abstract:
While attempting to mitigate care-recipient risk, in fact, the law has steadily expanded next-friend risk, by reinforcing a structure of long-term care that relies heavily on informal caregiving. Millions of informal caregivers face financial and nonmonetary harms that deeply threaten their own long-term security. These harms are disproportionately experienced by people who are already vulnerable--women, minorities, and the poor. Scholars and policymakers have catalogued and critiqued these costs but treat them as an unfortunate byproduct of an inevitable system of informal care.
This Article argues that if we, instead, understand becoming responsible for the care of another as a social risk--just as we see the chance that a person will need long-term care as a risk--it could fundamentally shift the way we approach long-term care policy.
As one informal caregiver and scholar described: “I feel abandoned by a health care system that commits resources and rewards to rescuing the injured and the ill but then consigns such patients and their families to the black hole of chronic ‘custodial’ care.” What next friends do for others is herculean, both in terms of the time spent and the ways that they offer assistance.
January 17, 2017 in Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Social Security, State Statutes/Regulations, Statistics | Permalink | Comments (0)
Thursday, November 24, 2016
We all need a little good news right now. So this one caught my eye. Dementia rates have declined amongst elders (yay). Kaiser Health News reported Dementia Rates Decline Sharply Among Senior Citizens citing to a study recently published in the AMA Journal of Internal Medicine. A Comparison of the Prevalence of Dementia in the United States in 2000 and 2012 reports on a drop from 11.6% to 8.8% on the years of the study.
Here's the abstract:
Importance The aging of the US population is expected to lead to a large increase in the number of adults with dementia, but some recent studies in the United States and other high-income countries suggest that the age-specific risk of dementia may have declined over the past 25 years. Clarifying current and future population trends in dementia prevalence and risk has important implications for patients, families, and government programs.
Objective To compare the prevalence of dementia in the United States in 2000 and 2012.
Design, Setting, and Participants We used data from the Health and Retirement Study (HRS), a nationally representative, population-based longitudinal survey of individuals in the United States 65 years or older from the 2000 (n = 10 546) and 2012 (n = 10 511) waves of the HRS.
Main Outcomes and Measures Dementia was identified in each year using HRS cognitive measures and validated methods for classifying self-respondents, as well as those represented by a proxy. Logistic regression was used to identify socioeconomic and health variables associated with change in dementia prevalence between 2000 and 2012.
Results The study cohorts had an average age of 75.0 years (95% CI, 74.8-75.2 years) in 2000 and 74.8 years (95% CI, 74.5-75.1 years) in 2012 (P = .24); 58.4% (95% CI, 57.3%-59.4%) of the 2000 cohort was female compared with 56.3% (95% CI, 55.5%-57.0%) of the 2012 cohort (P < .001). Dementia prevalence among those 65 years or older decreased from 11.6% (95% CI, 10.7%-12.7%) in 2000 to 8.8% (95% CI, 8.2%-9.4%) (8.6% with age- and sex-standardization) in 2012 (P < .001). More years of education was associated with a lower risk for dementia, and average years of education increased significantly (from 11.8 years [95% CI, 11.6-11.9 years] to 12.7 years [95% CI, 12.6-12.9 years]; P < .001) between 2000 and 2012. The decline in dementia prevalence occurred even though there was a significant age- and sex-adjusted increase between years in the cardiovascular risk profile (eg, prevalence of hypertension, diabetes, and obesity) among older US adults.
Conclusions and Relevance The prevalence of dementia in the United States declined significantly between 2000 and 2012. An increase in educational attainment was associated with some of the decline in dementia prevalence, but the full set of social, behavioral, and medical factors contributing to the decline is still uncertain. Continued monitoring of trends in dementia incidence and prevalence will be important for better gauging the full future societal impact of dementia as the number of older adults increases in the decades ahead.
The authors offer these findings from their study "Population brain health seemed to improve between 2000 and 2012; increasing educational attainment and better control of cardiovascular risk factors may have contributed to the improvement, but the full set of social, behavioral, and medical factors contributing to the improvement is still uncertain."
The Kaiser article offers some perspective about what this drop means: "The number of Americans over age 65 is expected to nearly double by 2050, reaching 84 million, according to the U.S. Census. So even if the percentage of elderly people who develop dementia is smaller than previously estimated, the total number of Americans suffering from the condition will continue to increase, said Keith Fargo, director of scientific programs and outreach, medical and scientific relations at the Alzheimer’s Association."
So with the end of the semester, and we are grading exams, just think how good this will be for us in the long run!
Tuesday, November 8, 2016
The Wall Street Journal recently published an article by Maddy Dychtwald, co-founder of Age Wave, on using virtual reality (VR) to help folks save. How Virtual Reality Can Boost Retirement Savings reports on a project and explains how it unfolded
Professor Hal Hershfield of UCLA’s Anderson School of Management partnered with Daniel Goldstein of Microsoft Research, Jeremy Bailenson, director of Stanford’s Virtual Human Interaction Lab, and several other Stanford researchers to see if connecting people with their future selves could affect their willingness to save for that future self. They took photos of college-age research subjects and digitally altered half of them to create virtual avatars at age 65—complete with jowls, bags under the eyes, and gray hair.
Why don't people do a better job of saving for retirement? According to the article, experts think it's psychological to some extent. "When you’re in your 20s and 30s, you can’t even imagine your life at 65 or 95. If you can’t imagine it, chances are you’re not planning for it."
Back tot he project. Digitally aging the participants wasn't the end of the project. Next the participants were provided with "goggles and sensors and were dropped into virtual reality, where they faced a mirror reflecting either their current self or their future self. As part of the experiment, they were each given $1,000 to spend. They could either buy a gift for someone special, invest in retirement, plan a fun event, or put money into a checking account."
This is getting intriguing. Want to bet what happened? According to the article, "[t]hose research ... greeted by their aged avatar put more than twice as much money toward retirement as those who saw their contemporaneous selves." The researchers, to double check the results, also showed "some research participants ... the aged avatars of other test subjects to see if that impacted their choices. It didn’t. Only those who saw themselves at retirement age were likely to invest in their future."
The WSJ article explains that VR tools are under development "to offer experiential solutions to our nation’s lack of retirement planning... [and] provide a visceral experience that might even immerse [the user] in several different future scenarios, so [the user] can experience, for instance, what it’s like to live with limited funds at 65, 75 or 80."
The article about the study, Increasing Saving Behavior Through Age-Progressed Renderings of the Future Self, is available here.
This is the abstract from the research study article:
Many people fail to save what they need to for retirement (Munnell, Webb, and Golub-Sass 2009). Research on excessive discounting of the future suggests that removing the lure of immediate rewards by pre-committing to decisions, or elaborating the value of future rewards can both make decisions more future-oriented. In this article, we explore a third and complementary route, one that deals not with present and future rewards, but with present and future selves. In line with thinkers who have suggested that people may fail, through a lack of belief or imagination, to identify with their future selves (Parfit 1971; Schelling 1984), we propose that allowing people to interact with age-progressed renderings of themselves will cause them to allocate more resources toward the future. In four studies, participants interacted with realistic computer renderings of their future selves using immersive virtual reality hardware and interactive decision aids. In all cases, those who interacted with virtual future selves exhibited an increased tendency to accept later monetary rewards over immediate ones.
Wow, just wow. Now, can we get these for our students?
Monday, October 10, 2016
Will New Federal Ban on Pre-Dispute "Binding" Arbitration Clauses in LTC Agreements Survive Likely Challenges?
My colleague Becky Morgan provided prompt links and important initial commentary for CMS's recently issued final regulations that are intended to "improve the quality of life, care, and services" in Long-Term Care (LTC) facilities. As we start to digest the 700+ pages of changes and commentary, it seems clear the battle over a key section that bans pre-dispute binding arbitration agreements is already shaping up. This rule, at 40 CFR Section 483.70(n), has an implementation date of November 28, 2016.
The regulatory ban on pre-dispute binding arbitration in covered facilities raises the question of "conflict" with the Federal Arbitration Act (FAA), 9 U.S.C. Section 1 et seq. The 2012 per curium ruling by the Supreme Court in Marmet Health Care Center, Inc. v. Brown, shapes the issue, if not the result.
CMS distinguishes Marmet and presents the rule change as based on authority granted under the Social Security Act to the Secretary of Health and Human Service to issue "such rules as may be necessary to the efficient administration of the functions of the Department," which necessarily includes supervision of all providers, including LTC providers, who "participate in the Medicare and Medicaid programs." CMS points to the long history of regulatory authority over LTC including long-celebrated "patient's rights" legislation adopted in the late 1980s. CMS further explains (at page 399 of the 700 page commentary to the new rules):
Based on the comments received in response to this rulemaking, we are convinced that requiring residents to sign pre-dispute arbitration agreements is fundamentally unfair because, among other things, it is almost impossible for residents or their decision-makers to give fully informed and voluntary consent to arbitration before a dispute has arisen. We believe that LTC residents should have a right to access the court system if a dispute with a facility arises, and that any agreement to arbitrate a claim should be knowing and voluntary. . . .
We recognize that an argument could be made that Medicare and Medicaid beneficiaries can assert in Court the FAA's saving clause if they believe that a pre-dispute arbitration agreement should not be enforced. However, the comments we have received have confirmed our conclusion that predispute arbitration clauses are, by their very nature, unconscionable. As one commenter noted, it is virtually impossible for a resident or their surrogate decision-maker to give fully informed or voluntary consent to such arbitration provisions. That same commenter 402 also noted that refusing to agree to the arbitration clause, in most cases, means that care will be denied.
Furthermore, Medicare and Medicaid beneficiaries are aged or disabled and ill. Many beneficiaries lack the resources to litigate a malpractice claim, much less an initial claim seeking to invalidate an arbitration clause. Rather than requiring Medicare and Medicaid beneficiaries to incur the additional fees, expense, and delay that would be the direct cost of opposing a motion to enforce arbitration, we have concluded that this is precisely the type of situation envisioned by the Congressional grant of authority contained in sections 1819(d)(4)(B) and 1919(d)(4)(B) of the Act authorizing the Secretary to establish "such other requirements relating to the health, safety, and well-being of residents or relating to the physical facilities thereof as the Secretary may find necessary.”
By coincidence, just hours before the final LTC rules issued by CMS, the Pennsylvania Supreme Court enforced pre-dispute arbitration agreements for nursing home residents in Taylor v. Extendicare Health Facilities (decided September 28, 2016).
The LTC industry seems ready to fight, as reported by industry insiders at McKnight's News on September 29, 2016:
Both the American Health Care Association and LeadingAge expressed disappointment in the arbitration ban in statements provided to McKnight's.
“That provision clearly exceeds CMS's statutory authority and is wholly unnecessary to protect residents' health and safety,” said Mark Parkinson, president and CEO of AHCA.
LeadingAge has supported arbitration agreements that are “properly structured and allow parties to have a speedy and cost-effective alternative to traditional litigation,” but believes CMS has overstepped its boundaries with the ban, the group said.
“Arbitration agreements should be enforced if they were executed separately from the admission agreement, were not a condition of admissions, and allowed the resident to rescind the agreement within a reasonable time frame,” LeadingAge added in its statement.
Stay tuned -- but don't hold your breath as the next round is likely to take some time. My special thanks to Megan Armstrong, Class of 2018 at Dickinson Law, for sharing key links with me for our research on this important development.
October 10, 2016 in Consumer Information, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, State Statutes/Regulations, Statistics | Permalink | Comments (0)
Thursday, September 1, 2016
A recent report about Boomers and voting made be stop for a moment and go "hmmmm". Pew Research Center's latest FactTank offered that this may be the last presidential election where the Greatest Generation, the Silents and the Boomers have a significant impact at the polls.
This may be the last presidential election dominated by Boomers and prior generations explains that although these demographic groups have dominated at the polls, that may no longer be true; "their election reign may end this November, according to a new Pew Research Center analysis of census data."
[T]he ranks of Millennial and Generation X eligible voters have been growing, thanks to the aging-in of Millennials and naturalizations among foreign-born adults. These generations matched Boomers and previous generations as a share of eligible voters in 2012 and are now estimated to outnumber them. As of July, an estimated 126 million Millennial and Gen X adults were eligible to vote (56% of eligible voters), compared with only 98 million Boomers and other adults from prior generations, or 44% of the voting-eligible population.
However, keep in mind that eligible and actual are not synonymous. In fact, the article reminds us what ultimately matters is who casts ballots. Looking at the data and focusing on actual votes, the report offers that the Boomers and prior generations voted at a rate of about 70% of eligible voters. The younger generations percentage turnout was lower, according to the article.
Not that the generations are in competition or anything. It's just interesting to think about the changing demographics at the ballot box and wonder at the impact on laws and policies as a result.
Among those in the oldest living generation, the Greatest Generation, turnout crested in the 1984 election at 76% before declining. Similarly, turnout among eligible voters in the Silent Generation peaked at 76% in the 1992 election. The Millennial and Gen X generations are likely still on the upswing in terms of their turnout rates, so it is a reasonable guess that at least 54.5% of these adults will vote, and perhaps more.
We won’t know until after November if Boomers and their elders will pass the torch to Gen X and Millennials as a share of voters, but all the available data suggest that the 2016 election will mark the beginning of a new era for U.S. presidential elections.
Wednesday, August 24, 2016
Dickinson Law Professor Laurel Terry sent me a timely link to an NPR story about Japanese convenience stores. I was already thinking about how retail shopping has changed over the years. For example, on the corner of 7th Avenue and Indian School Road in Phoenix, there used to be a high-end Scandinavian furniture store. I'd only been in it once, and that was to use a gift certificate for what seemed like a huge amount of money at the time as a wedding present. My husband and I realized the most we could afford in the store was a wooden bowl. A very nice wooden bowl, mind you, but still, it was a wooden bowl.
Yesterday, as I passed that corner, I realized there was still a big, fancy sign out front, but the store is now a Goodwill franchise store.
So, with that change in mind, I enjoyed the NPR story, captioned Beyond Slurpees: Many Japanese MiniMarts Now Cater to Elders. From the written account:
Case in point is a Lawson convenience store in the city of Kawaguchi, north of Tokyo. It sells products that an American consumer would never find tucked between the aspirin and the candy bars. For example, there's a whole rack of ready-to-heat meals in colorful pouches. They're rated at levels from 1 to 5, based on how hard it is to chew what's inside.
Or, as the store's manager, Masahiko Terada, puts it, "the higher the level, the less need for you to chew. In the end it's porridge."
This Lawson store in Kawaguchi is one of six in a special line called Care Lawson. The company plans to expand to 30 by early next year. And these Care Lawson stores have another special feature: staff like Mika Kojima.
She's a nursing care manager and she's stationed at this Lawson store. In fact the franchise owner of this store is actually a nursing services company. Anyone who comes in can ask for Kojima's help. For example, she'll go to an older client's home to make sure it's set up so they can live there safely. And she'll connect families with adult day care services.
Convenience stories should be just that, convenient, right? With adults over age-65 making up nearly 27 percent of Japan's population, it just makes sense for retailers to provide customer-specific merchandise that is easily accessible, especially for people who might prefer to avoid large supermarkets. The Lawson chain also offers home deliveries.
The story made me wonder more about Lawson. How was it that the Japanese chain came to have such a non-Japanese name? It turns out Lawson began back to 1939 in Ohio, in the United States, where J. J. Lawson ran a dairy milk store. "'Mr. Lawson's milk store' was locally renowned for its fresh and delicious milk and many customers came to buy milk there every morning." The first Lawson convenience store opened in Japan in 1975 and sold "party food," very different from the model of today.
Friday, August 19, 2016
I'm always just a bit suspicious of books that promise to make me laugh. I think it is because I like to be surprised by humorous moments, rather than feel duty-bound to chuckle, guffaw or giggle.
Nonetheless, I succumbed to the promise in the blurb for Michael Kinsley's 2016 book, Old Age: A Beginner's Guide, that it was a "surprisingly cheerful book ... and a frequently funny account of one man's journey to the finish line."
And I'm glad I did. I did indeed laugh, and at the most surprising of moments, as when he described the need to avoid the doors of his refrigerator because of the magnets that might interfere with the technology in his brain used to keep symptom of Parkinson's Disease at bay. He has the knack of making wry observations about his own mortal state to think broadly about what it is for all of us to age. I can see the short essays that make up this book being useful in a class on elder law or estate planning.
His words are perhaps most poignantly relevant to boomers. For example, on a goal of living longer, he writes:
Even before you're dead, you may want to ask yourself whether this is what you really want. Is being alive all that desirable if you're alive only in the technical sense? Millions of boomers are watching their parents fade until they are no longer there. As they approach their seventies, they start observing their own peer group losing their collective marbles, one at a time. And they reasonably conclude that the real competition should not be about longevity. It should be about cognition.
But he doesn't stop there, exploring other, potentially more important goals for the competitive boomer generation to consider.
This is a short, deep book. And I recommend it, not least of all because it gives readers welcome opportunities to smile.