Posts Tagged ‘dementia’

Staying Mentally Alert

NOVEMBER 28, 1994 VOLUME 2, NUMBER 21

Many casual observers fall into the trap of believing that confusion (and, indeed, dementia) is the normal result of the aging process. It should not (but does) require repeating that mental acuity continues throughout most of our lives.

An ongoing study of elderly nuns conducted by the University of Kentucky is helping to shed some new light on the normal aging process in the human brain. Nearly 700 members of the School Sisters of Notre Dame have given researchers full access to their medical records and agreed to donate their brains for autopsy upon death. Some of the early study results are interesting and provocative.

One of the more interesting individual study participants died at the age of 102. She was notable for her full mental command right up to her death, yet researchers were surprised to find that her brain exhibited all the physical symptoms of Alzheimer’s disease. Researchers’ initial conclusion: her mental functioning remained intact by virtue of her high educational level and regular mental exercise.

Similar conclusions have been drawn from another study conducted by Penn State University’s Gerontology Center on patients who had been followed for fourteen years. In that project, 70 and 80-year-old patients were given tutoring sessions and retested on spatial skills, inductive reasoning, vocabulary and number skills. Two-thirds improved their mental functioning; forty percent returned to the level of functioning they had demonstrated fourteen years earlier.

The clear message sent by these and other similar studies is that mental workouts are good for the elderly. Conversely, inactive pastimes (such as passive television viewing) should be seen as contributing to, and perhaps even as causing, the mental decline of the elderly. As Dr. David Snowdon, director of the University of Kentucky study, says: “People go to the gym and work on their muscles and bones, but what about the brain?”

Inflation in Medicine

The federal government has just released figures for 1993 medical costs. The bad news: inflation in medical costs continues to exceed the general cost of living increases. The good news: the inflation in medical costs was the lowest in seven years.

The average medical bill for an American in 1993 totalled $3,299. That was only $205 (or 7.8%) more than the 1992 figure.

Medical costs consumed one-seventh of Americans’ income in 1993. The health care share of the gross domestic product increased from 13.6% in 1992 to 13.9%.

Still unclear is the reason for the decrease in growth of medical costs. Some health-care experts theorize that discussion of health care reform, even though it did not result in legislative changes, has triggered an industry restructuring.

Local Alzheimer’s Support Project

SEPTEMBER 12, 1994 VOLUME 2, NUMBER 10

Tucson’s Jewish Family and Children’s Service Center and the Southern Arizona Chapter of the Alzheimer’s Association have announced the receipt of a $46,809 grant from the Flinn Foundation. The grant money will be used to establish a program to provide relief for family caregivers of dementia, Parkinson’s and stroke patients.

The program will utilize volunteers to provide respite care. Volunteer recruitment, supervision and retention will be the responsibility of the Jewish Family and Children’s Service Center, and the Alzheimer’s Association will develop a training program for the volunteer caregivers.

Once established, the program will provide volunteer relief caregivers for some families. There will be no fee, but families will be permitted to make contributions toward the cost of the program.

State Medicaid Waivers Challenged

States may have a more difficult time securing federal waivers to permit experimental Medicaid programs in the future. A lawsuit filed by a group of community health clinics against state plans in Tennessee and Oregon challenges the use of such waivers.

Under federal Medicaid administrative rules, states must secure specific waivers before implementing variations on Medicaid funding or service delivery structures. Arizona has operated under such a waiver since the establishment of its AHCCCS program.

The Clinton administration has indicated its intention to permit state experimentation by making the waiver process easier for states to navigate. The Tennessee experiment, for example, would transfer Medicaid recipients into health maintenance organizations and other discount-price networks of health providers. Similar waivers have already been granted to Hawaii and Rhode Island, and another half dozen states have either applied for waivers or are considering doing so.

The lawsuit alleges that the effect of the waivers is to permit state-by-state health care reform, rather than to encourage Medicaid improvement. The clinics also claim that low-income patients are hurt by placing them in HMOs, because they need health education and encouragement to seek care. Since HMOs are rewarded when patients make fewer visits to the doctor’s office, they are not a good way to deliver care to the poor, according to the suit.

Zinc and Alzheimer’s

SEPTEMBER 5 1994 VOLUME 2, NUMBER 9

A new laboratory finding suggests that excess zinc may be implicated in triggering the onset of Alzheimer’s disease. The experimental results were reported in last week’s issue of Science.

Researchers added minute amounts of zinc to solutions containing chemicals normally found in the brain. The mineral apparently caused amyloid plaques to form; such glue-like clumps are one of the main hallmarks of Alzheimer’s disease.

Similar experiments with other minerals did not produce amyloid plaques in the laboratory. Of particular interest was aluminum, which has been implicated in some previous studies as potentially being involved in Alzheimer’s disease; aluminum did not cause clumps to form.

Previous studies of Alzheimer’s patients had found elevated levels of the mineral in two places. In one, excess zinc was found in cerebrospinal fluid of demented patients. In the other, particularly high levels of zinc were found in the hippocampus of Alzheimer’s patients, an area of the brain known to be involved in the recording of memories.

Dr. Rudolph Tanzi, chief researcher in the new study on zinc, was quick to note that his study does nothing more than increase the suspicion about zinc. Further research is necessary, he notes, before recommendations can be made about dietary changes. Small amounts of zinc are required for various metabolic processes in the body, and zinc deficiency could lead to slow wound healing, loss of appetite and other problems. Zinc is found naturally in meats, eggs and shellfish.

One of the concerns raised by this new research is the occasional use of massive zinc supplements to treat a variety of illnesses. Some practitioners recommend zinc to prevent prostate cancer and macular degeneration, for instance. Some controversial reports even have suggested that zinc may improve the immune system and increase mental alertness in the elderly.

In fact, one reason Dr. Tanzi began the current study of the effects of zinc was his familiarity with an unpublished study in Australia. In 1992, researchers in Melbourne sought to test theories that zinc might actually improve mental functioning among Alzheimer’s patients. Five patients suffering from dementia were given zinc supplements; within four days their cognitive functioning had deteriorated so markedly that the study was halted.

Even armed with the Australian research results, Dr. Tanzi still cautions against over-reaction. He notes that zinc is already known to be dangerous in large doses, and speculates that Alzheimer’s patients may simply be unusually susceptible to its toxic effects. Still, the results of these two studies may caution against the practice of using megadoses of zinc; some doctors prescribe up to fifteen times the recommended daily allowance of fifteen milligrams for macular degeneration patients. Dr. Tanzi’s group now plans to test such patients for increased Alzheimer’s risk.

Fleming & Curti, P.L.C.

Elder Law Issues publisher Robert Fleming and long-time Tucson attorney Thomas Curti have formed a law partnership. Fleming and Curti have shared space in their jointly-owned office building in the “snob hollow” neighborhood downtown for over two years, and have had a long professional association prior to this recent change. In fact, the two were law school classmates in the early 1970s.

The focus of the firm will continue to be Elder Law and related issues, but with the ability to work in business, real estate and personal injury law. Addresses and telephone numbers are unchanged.

Recent Court Cases

AUGUST 22, 1994 VOLUME 2, NUMBER 7

Some recent court cases of note to those caring for or working with elders:

Assaultive Resident Can Not be Moved from Nursing Home

“E.R.” is a demented patient residing in a Washington State nursing home, Park West. E.R. sufered a stroke in 1991 which reduced his ability to control sexual impulses. E.R. repeatedly engaged in sexually assaultive behavior. Park West placed him on a “15-minute alert”, which required that staff members physically view E.R. at least every fifteen minutes. E.R. was also moved to a private room.

Nevertheless, E.R.’s behavior continued. Finally, Park West served E.R.’s guardian with a notice intended to require the guardian to find a new placement for E.R. The notice purported to require the guardian to move E.R. to another facility. It noted that E.R.’s needs could not be met at Park West, and that his conduct endangered the safety of other residents.

E.R.’s guardian opposed the transfer and requested an administrative hearing. The Administrative Law Judge ultimately ruled that Park West could not force the guardian to make the move. The ALJ ruled that E.R. had rights pursuant to OBRA93, the Fair Housing Amendments Act and the American’s with Disabilities Act, and that Park West did not have authority to order his removal unless he posed a danger to other residents that could not be eliminated by a plan of care. The Administrative Law Judge specifically found that E.R.’s supervision was “intermittent and inconsistently applied.” E.R. was permitted to remain at Park West and the facility required to develop and implement a care plan to deal with his actions. In re E.R., Washington State Office of Hearings and Appeals, DSHS, March 16, 1994. [Note that the result might well have been different if E.R. had lived in Arizona.]

Trust Available to Medicaid Applicant

When Pennsylvanian Louis Rosenberg died in January, 1976, his Will left $65,000 in a trust for his wife Mary. The trust required provided for income to be used for Mary, and also permitted use of principal for her medical and surgical expenses and other “unusual” needs.

In 1992, Mary Rosenberg (by then living in a nursing home) exhausted her personal assets. Her son (who was also one of the trustees of the trust) applied for Medicaid long-term benefits on her behalf. The state Medicaid agency denied eligibility, finding that the trust principal was “available” to Mary. Her son appealed on her behalf unsuccessfully.

Mary died shortly thereafter, and her estate sought judicial review of the denial. The court agreed with the Medicaid agency, finding that Louis had intended to make the funds available to pay for Mary’s medical bills, including nursing care. Rosenberg v. Dep’t. of Public Welfare, Penn. Commonwealth Court, June 13, 1994. [This case, with its unsurprising result, points out the importance of knowledgeable drafting of estate planning documents when long-term care is anticipated.]

More Recent Court Cases

AUGUST 2, 1994 VOLUME 2, NUMBER 8

Some recent court cases of note to those caring for or working with elders:

Trust Not Changed by Divorce

Horace and Victoria Collins were married when Horace prepared his living trust. He left half of his separate property to his wife and most of the rest to his grandchildren. Later, the couple divorced. Horace died without changing his living trust.

Arizona’s statutes provide that, when a person divorces, his will is automatically modified to disinherit his former spouse. He may choose to change his will after the divorce, and may even leave property to his “ex”, but until he makes a change or renews his will, the law will effectively rewrite his will.

Horace’s grandsons argued that the same provision should apply to living trusts. By their logic, Victoria would be “written out” of Horace’s trust, on the assumption that Horace would have done the same thing himself if he had gotten around to it.

The Pima County Superior Court Judge disagreed. He ruled that the statute on revising wills applies only to wills, and not to living trusts. Some evidence existed that Horace intended to leave Victoria in his trust, even after the divorce, but the judge ruled that Horace’s intentions need not be demonstrated. In re: Horace Collins Revocable Trust, August, 1994.

[Effective January 1, 1995, a new Arizona law will change this rule. In addition, life insurance benefits and other beneficiary designations will be automatically changed by divorce–Ed.]

Trust Invalidated Despite Attorney’s Involvement

Agnes Rick was already suffering from dementia when her husband of fifty years died in 1990. Afterwards, neighbors helped her with meals, transportation and bill-paying. One of those helpful neighbors was stockbroker John Sailer, Jr.

In 1992, Ms. Rick conveyed a large parcel of land to a corporation owned by Sailer. He also took her to an attorney who, at his suggestion, prepared a living trust and power of attorney naming Sailer as fiduciary and giving him an option on her home at a below-market price.

Ms. Rick’s niece brought a conservatorship proceeding, alleging that Mr. Sailer was taking advantage of her. The attorney who prepared the documents, along with his associate and his secretary, testified that Ms. Rick knew what she was doing. The Delaware trial judge rejected their testimony, while indicating that he did not doubt that the witnesses genuinely believed they had carried out Ms. Rick’s wishes at the time.

The judge noted that the drafting attorney was not Ms. Rick’s regular attorney, but was selected by Mr. Sailer, and that he did not know about her medical history, family background, failing memory or dependence on others. Had the lawyer known, the judge said, he surely would have asked more detailed questions. In the Matter of Rick, 1994.

Shortage of Geriatrics Specialists

JUNE 20, 1994 VOLUME 1, NUMBER 30

The U.S. is suffering from a serious shortage of doctors trained to care for elderly patients. A recent New York Times article reported that “while the number of older Americans is rising quickly — particularly those over 85 and in the frailest health — experts say the number of doctors trained to meet their needs is in critically short supply.”

A 1980 study conducted by UCLA projected that by 1990 the U.S. would need 13,000 geriatric specialists to deal with the anticipated elderly population. In fact, the total number of geriatricians practicing in the U.S. today is approximately 4,000, or less than one-third the anticipated need.

The usual explanations for this chronic shortage of geriatric specialists include:

  • A reluctance by doctors to face aging and death,
  • Poor reimbursement rates for geriatric medical services, particularly by government programs, and
  • A shortage of academic leaders and role models in geriatrics.

In addition to the shortage of geriatric specialists, there is a growing problem of inadequate training in geriatric issues for other physicians. Of the 126 U.S. medical schools, only 13 require course work in geriatrics, and only 2 others offer geriatrics as an elective course. Most medical schools cover geriatric issues as part of their general curriculum, but experts say this approach is insufficient given the scope of the training shortage.
There are currently about 32.3 million Americans over age 65. Within the next 40 years, that number is expected to more than double, to about 70 million. At the same time, the number of Americans over age 85 (the frailest elderly, and those needing the most specialized care) will almost triple, from about 3 million to nearly 9 million.

While those over 65 make up about 13 percent of the population, they account for about 30 percent of the nation’s health care costs, 44 percent of all hospital days and 40 percent of all internists visits. While the need for more geriatric specialists seems obvious, the supply is simply not keeping pace with demand.

Nursing Homes, Too

Approximately 1.8 million Americans lived in nursing homes in 1990, according to Census figures. That represented a 24 percent increase during the 1980s, a rate of increase that was approximately double the general population growth rate.

Within the next quarter-century, the number of nursing home residents is expected to more than double. According to projections by the Brookings Institution, there will be four times as many nursing home residents at the end of the next half-century unless there are fundamental changes in the way we deal with the elderly.

About half of the current population of nursing home residents suffer from some form of dementia. The projections for future use assume that the rates of dementia and institutionalization continue about the same in the next half-century. Much of the increase in nursing home population will come from the aging “Baby Boomer” generation, as its oldest members will turn 65 in fifteen years.

Those same “boomers” are just beginning to face the prospect of nursing home placement — for their parents. According to a 1993 Gallup poll, most Americans are more frightened by the prospect of placing a parent in the nursing home than by the prospect of that same parent’s sudden death.

The “boomers” have been characterized as demanding consumers and prepared to shop around more readily than their parents. Their effect on the nursing home marketplace should be interesting to observe.

Health Costs Rise

MAY 2, 1994 VOLUME 1, NUMBER 23

The average older American will spend $2,803 out-of-pocket on health costs this year, according to a study by the American Association of Retired Persons and the Urban Institute. That amounts to 23 percent of the income of the same “average” elder.

In 1987, a similar study found that the health care bill was half the current figure, and it amounted to only 17 percent of income of the elderly. Out-of-pocket expenses include Medicare co-payments, drugs and insurance premiums.

For those under 65, health care costs are dramatically lower. Younger Americans spend an average of $679 a year, which is 8 percent of income.

The elderly use far more medical services. They go to the doctor twice as much, are hospitalized three times as much and purchase four times as many prescription drugs, according to the study.

More Elderly Arizonans

According to new Census Bureau projections, Arizona should become one of the “oldest” states in the country by 2020. Only Florida is expected to have a higher percentage of over-65 residents.

13% of Arizona’s population is now over age 65, which places the state 18th in the nation. The number of elderly Arizonans is expected to double in the next 25 years, which will mean that 20% of the population is over 65.

The same projections suggest that Arizona will become more ethnic in the next quarter-century. Asian, Indian and Hispanic populations are expected to grow faster than the rest of the state. Arizona should have the largest Indian population in the country by the end of this century.

Alzheimer’s Research

A new study suggests that the protein long known to be present in advanced Alzheimer’s patients may cause memory loss very early in the disease progression. The study, published in Sciencemagazine last month, shows that tiny amounts of the protein, beta amyloid, can interfere with potassium use in healthy cells. The results suggest that calcium is not the major culprit that it was thought to be.

Alzheimer’s is thought to affect as many as 4 million Americans. !00,000 deaths are attributed to the disease each year.

Racism and Dementia

From Wall Street Journal, 4/29/94

“The average nursing home combines mostly elderly white patients raised long before the civil rights movement and a staff of many nonwhites and immigrants. A New York nursing home is trying to protect those caregivers from the disturbing racist behavior of some Alzheimer’s patients.

At a recent weekly support meeting at the Hebrew Home for the Aged at Riverdale, whose staff is 73% nonwhite, nurses and nurses’ aides wondered aloud at how some befuddled patients can lucidly fall back on racial attitudes from the Depression. ‘There are memories that are riveted to the things of the past. They will remember their parents’ names…and that you are a nigger,’ says a nurse from Jamaica. The problem is particularly troublesome because the nurses’ 50 patients are in the early stages of dementia and sometimes seem to be responsible for their outbursts, says social worker Robin Bouru.

Despite the offensive incidents, the staffers have high morale and say they often develop close relationships with their patients. Training coordinator Myra Bryce Richardson advises the nurses to overcome the urge to retaliate by seeing the verbal attacks as symptoms of illness, not character. Preliminary results of a study at 15 New York-area nursing homes suggest that regular in-service training makes nurses less likely to take it personally, reducing stress on the job.

ALTCS and Community Resources

JANUARY 31, 1994 VOLUME 1, NUMBER 11

A little-known and seldom-used section of federal law may provide relief for married couples who have difficulty meeting asset limitation for Arizona Long Term Care System (ALTCS) eligibility. The relatively obscure provision requires ALTCS to increase the value of assets which a “community spouse” is entitled to retain under some circumstances.

Most workers who deal with ALTCS eligibility are familiar with the concept of a “Community Spouse Resource Allowance” (CSRA). When one spouse enters a hospital or nursing home, the community spouse may retain half the assets “available” to the community at the time of admission (plus the residence and some other assets). The maximum amount of this Allowance is usually $72,660.

For some poorer couples, the government’s largesse may permit retention o all (or nearly all) the community’s assets. No matter how little is available at the time of admission, the community spouse is always permitted to retail a minimum of $14,532 in addition to the residence, vehicle and some other assets.

Can You Pronounce MMMNA?

But the maximum CSRA is not really $72,660. The obscure (but highly useful) provision that requires a higher CSRA is found in 42 United States Code Section 1396r-5(e)(2)(C). That law, which is binding on Arizona’s ALTCS program, provides that:

If…the community spouse resource allowance… is inadequate to raise the community spouse’s income to the minimum monthly maintenance needs allowance, there shall be substituted, for the community spouse resource allowance…an amount adequate to provide such a minimum monthly maintenance needs allowance.

But what on earth is a “minimum monthly maintenance needs allowance?” In a different context, Congress decided that a community spouse should be entitled to retain the first $1179 of community income to ensure sufficient funds to maintain basic needs (this number can also be increased in some circumstances). All section 1396r-5(e)(2)(C) says is that the community spouse is entitled to retain enough assets to guarantee that he or she receives that $1179 per month, even though that may be more than the $72,660 (or whatever the CSRA equals in an individual case).

Fair Hearings

There is one catch to the increased CSRA. Eligibility officers are not able to invoke the provision during the initial eligibility application. The higher CSRA can only be granted after a “fair hearing”–usually in the course of an appeal from the denial of eligibility. But since most eligibility workers are unfamiliar with the provision, and since no one is telling applicants to appeal from denials (ALTCS usually just talks applicants into withdrawing applications), many eligible couples may be denied benefits to which they are entitled.

In such cases, it may be advisable for applicants to have legal counsel during the application process and subsequent appeal. Substantial assets may be retained by the community spouse, making the cost of legal advice seem reasonable by comparison.

Safe Return

Demented patients who wander away from home care settings can be very difficult to deal with. For many family members, the fear of losing a wandering family member may make it impossible to keep a patient at home.

While it does not provide a complete solution, the Alzheimer’s Association has come up with a plan to help families deal with anxiety about wandering. The “Safe Return” program provides an identifying bracelet, a national registry, an 800 number contact system, and wallet and garment tag identification for patients prone to wandering. The year-old national program may provide peace of mind for family caretakers, and has the potential to save patient’s lives and permit community placement in more instances. For information about Safe Return, contact the Alzheimer’s Association at (800)272-3900.

Dementia and Art

JANUARY 17, 1994 VOLUME 1, NUMBER 9

Anne Watts, a 31-year-old composer and singer, has spent the past year turning nursing home residents into artists. She believes that her efforts help patients deal with the loss of self inherent in dementia.

Watts practices her unconventional therapy in conjunction with Meridian Healthcare, Inc., nursing homes in Baltimore. Rather than the more conventional art therapy programs found in other institutions, her approach has been to link individual artists from the community with single nursing home residents. The participants choose their own medium and control the artistic process.

According to an article in The Wall Street Journal (January 13), the results have been positive. Meridian’s director of Alzheimer Services notes that “most health-care workers underestimate the capacities of demented patients.” Watts’ nursing home artists, though suffering from varying degrees of dementia, have completed ceramics, collages, quilts, paintings and other art works.

The personal growth and expansion of horizons seems to have worked in both directions. One of the outside artists recruited to work with the demented elderly, multimedia artist Cathy Leaycraft, says that her first reaction to the nursing home project was that “I was horrified, thinking why would they want to be alive? But after a while, I saw they weren’t really ready to die yet, there were still things going on, spiritual kinds of things.”

Watts’ original idea grew out of her contact with nursing home resident John Englehart in 1986. Englehart was institutionalized in 1918, and diagnosed as retarded and schizophrenic. Heavily medicated with Thorazine, he had not spoken for fifteen years when Watts gave him a felt marker and a piece of paper. Englehart not only produced a detailed drawing, but also identified the subject of his art work as a “windmill.”

Over the next four years Englehart produced scores of drawings and paintings. He was critically acclaimed, and his works were sold at a one-man show in Baltimore. Englehart died two years ago at age 85.

Watts acknowledges that Englehart’s artistic awakening was very unusual. Nonetheless, it is the image of the man she initially described as “this horrifying, gnomish creature” that keeps her involved in the project. “It is scary for all of us,” says Watts, “to think of a future in a lonely place where we aren’t given the opportunity to do our work and where no one wants to hear what we have to say before we die.”

Q & A

Q: When is a nursing home resident determined to be incompetent so that a health care agent has power to make medical decisions? Who determines incompetency?

A: The Health Care Power of Attorney statute (A.R.S. §36-3221) is operative when the patient is “unable to make or communicate health care treatment decisions.” In most cases it is not necessary to have any formal determination of incompetence since the patient and agent will agree about care decisions. If there is disagreement, of course, the patient’s decision will prevail unless he or she is clearly incompetent. Even an incompetent patient should be consulted about health care decisions (for therapeutic reasons if not for legal reasons).

If no consensus can be reached the Court must decide the patient’s competence, based on medical testimony. The whole purpose of health care powers of attorney, however, is to avoid courts and lawyers as much as possible. In most cases, that goal should be easy to meet.

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