Posts Tagged ‘depression’

Updated information re: hoarding

Turns out that hoarding behaviors may be more properly associated with depression than with obsessive/compulsive disorders. Also that hoarding problems tend to worsen with age. Read more in a National Public Radio report on a recent national meeting on aging issues.

Both pieces of news square with our observations. They also lead to the conclusion that simply conducting a massive clean-up may not only be ineffective, but also counterproductive.

Illinois Woman’s Death Does Not Give Rise To Family Claim

MARCH 17, 1997 VOLUME 4, NUMBER 37

Dorothy Ficke was admitted to an Evangelical Health Systems hospital in Illinois in March, 1993. Ms. Ficke was 81 years old and suffered from a recent stroke, and diabetes, arthritis, gout, hypertension, congestive heart failure, respiratory disease and depression.

Ms. Ficke had never signed a Living Will or Health Care Power of Attorney, but her hospital chart was marked Do Not Resuscitate by her physician, Dr. Jose Aruguete, a little more than a week after her admission. Ms. Ficke died soon after.

Claiming that they had not been told about Illinois’ law permitting surrogates to make health care decisions, and that they had been forced to stand by while Dr. Aruguete continued to aggressively treat their mother, Mrs. Ficke’s children Darlene, Thomas and Michael brought suit against Dr. Aruguete and the hospital. Their claim against the hospital asserted that hospital staffers knew that Ms. Ficke lacked capacity and that the hospital took no steps to determine whether family members could make health care decisions for her; they also argued that the hospital failed to tell them they had the power to make decisions regarding her care.

The Illinois trial court judge dismissed the Ficke children’s suit against the hospital, and they appealed. The Illinois Court of Appeals has now agreed that the children have no lawsuit against the hospital.

Illinois’ law is similar to Arizona’s surrogate decision-making law. It provides that, where a patient is terminally ill, permanently unconscious, or suffering from an incurable or irreversible illness, family members may make decisions regarding health care even if the patient has not signed an advance directive. [Ed. note: Arizona law permits the family member to make any decision except a decision to withhold or withdraw food or fluids]

The Court of Appeals decided that any fault in Ms. Ficke’s case could not be assigned to the hospital. Although the hospital has a duty to determine whether surrogates are available to act, it must do so only after the terminal condition, permanent unconsciousness or incurable or irreversible condition has been certified. “[I]t is for the attending physician, not the hospital or its staff,” said the Court, “to determine whether the Act applies to a particular patient.” In other words, any claim the family may have must be against Dr. Aruguete.

Furthermore, the Court found that family members do not have a cause of action for their own suffering from having to watch the treatment and, ultimately, the death of their mother. While their mother’s estate might have a claim against Dr. Aruguete, the law does not provide protection for family members; to do so, said the Court, would leave open the question of whether only close family members might make claims, or only those family members who truly “cared about” the decedent.

Although not a model of linguistic clarity, the Court acknowledged that “the death of a parent is indeed an event occasioned by the continued suffering or grieving of the decedent’s family.” Suffering and grieving, however, do not give rise to a legal claim. One member of the three-judge court disagreed with the majority, arguing that the family members should have a cause of action against the hospital because the facility knew (or should have known) that Ms. Ficke was in fact covered by the surrogate law, whether or not her physician filled out the requisite form certifying her condition. Ficke v. Evangelical Health Systems, Illinois Court of Appeals, December 13, 1996.

Although Arizona law is similar in some respects, it is not clear whether the same result would be reached in similar facts. Absent special circumstances, facilities are well-advised to consider the wishes of family members regarding cessation of life-sustaining treatment.

Phoenix Seminar on Preventing Abuse, Neglect, Exploitation


Last week in Phoenix, the Maricopa Elder Abuse Prevention Alliance hosted a two-day seminar on prevention of abuse, neglect and exploitation of the elderly. Speakers ranged from nationally-known advocacy leaders to local social service and legal practitioners.

Jeff Calvert, coordinator of the Alliance, listed some of the warning signs of abuse, distinguishing between physical signs (burns, bruises, decubiti, malnutrition, etc.) and behavioral signs. Calvert noted that many behavioral conditions may exist in elders not subjected to abuse, but that they may also indicate something is amiss. His list included:

  • Agitation, anxiety
  • Withdrawal
  • Isolation
  • Confusion
  • Fear
  • Depression
  • Anger
  • Disorientation
  • Resignation
  • Hesitation to talk openly
  • Implausible stories
  • Non-responsiveness

Donna M. Reulbach, director of a Massachusetts program to prevent financial exploitation by involving bank tellers and officers, described her agency’s efforts with banks. She also listed some of the indicators that financial professionals can use to recognize exploitation. The elder customer may be:

  • accompanied by a stranger who urges large cash withdrawals
  • in the company of family members who appear to speak for the elder and make all decisions
  • nervous or afraid of the person accompanying them
  • giving implausible explanations about financial matters
  • unable to remember transactions
  • fearful that they will be evicted (or sued) if money is not given to a caregiver
  • isolated from family or supports (or isolated from family other than the relative accompanying them to the bank)

Lori Stiegel, Associate Staff Director of the American Bar Association’s Commission on Legal Problems of the Elderly, described national trends in prevention and punishment of abuse, neglect and exploitation. She noted that Arizona’s recent inclusion of “emotional abuse” in its criminal statute, coupled with the broad definition of “vulnerable adults” as the group entitled to special protection, made Arizona one of the more progressive states in dealing with problems of abuse, neglect and exploitation.

Phoenix prosecutors Terri Clarke and Pamela Svoboda, together with Phoenix Police Lieutenant Ken Tims, described the goals of and problems encountered by a concerted program to prosecute abusers. Their most notable concern: the difficult in prosecuting cases where the victim may be incapacitated, ill, or deceased, or may now be denying any abuse took place. They noted that abused elder women may commonly suffer from low self-esteem, come from traditionalist backgrounds, demonstrate “learned helplessness” and see their own role as keeping the peace between the abuser and the rest of the family (or society).

Phoenix Doctor Walter J. Nieri noted that many instances of abuse and neglect (as well as some examples of financial exploitation) come from long-term care settings. While nursing homes are closely regulated, and the possibility of undetected abuse is consequently lower, adult care homes are much more numerous and subjected to less state monitoring. He also pointed out that much abuse and neglect can be traced to caregiver stress, and provided a checklist for assessment of the level of stress in individual cases.

Susan Aziz and Chayo Reyes described the Los Angeles Fiduciary Abuse Specialist Team, a multi-agency task force established to combat the “crime of the nineties:” elder financial abuse. The three-year-old program involves Police, Public Guardian, Adult Protective Service and Probate Court representatives, among others. The Team conducts training sessions and focuses on fiduciary abuse.

Frequency of Dementia Varies By Age, Diagnosis, Placement

JULY 15, 1996 VOLUME 4, NUMBER 3

The common usage of “dementia” usually refers to loss of intellectual functioning or diminished mental capacity. Frequently, the term is used to describe any of a wide variety of illnesses or conditions, without distinguishing among the possible causes.

In a similar way, “Alzheimer’s” is commonly used to describe almost all demented individuals, regardless of the actual reason for the diminution of capacity. It is commonly understood that Alzheimer’s Disease is a diagnosis of exclusion; other than autopsy, it is usually impossible to definitively diagnosis Alzheimer’s, and the diagnosis is reached by excluding all other possible diseases.

For many purposes, the difference between a diagnosis of Alzheimer’s and, for example, vascular dementia is unimportant. Most dementias are irreversible, and there is little evidence to suggest that the progress of many dementing illnesses can be slowed. Still, it is both important and interesting to know what different illnesses might cause dementia, and the relative frequency of each.

In their 1992 book “Dementia: A Clinical Approach,” medical researchers Jeffrey L. Cummings and D. Frank Benson survey the existing literature about dementia. Among demented patients, the frequency of each cause varies according to the researcher. Cummings and Benson caution that the estimates of Alzheimer’s disease, in particular, are almost certainly overstated, but the research suggests the following frequencies:

  • Alzheimer’s Disease–25-50%
  • Vascular (multi-infarct) Dementia–10-25%
  • Depression and other psychiatric disorders–10-20%
  • Alcoholic Dementia–2-12%

Other causes, each accounting for between one or two percent and ten percent of all dementias, include metabolic conditions, infections, toxic conditions, Huntington’s and Parkinson’s diseases and other, less frequent causes.

Clearly, Alzheimer’s Disease is the most common dementing condition, but other causes collectively account for more dementia. The very fact that Alzheimer’s is a diagnosis of exclusion operates to inflate its reported frequency, since unidentified dementias will usually be lumped into that category.

Cummings and Benson also report several studies about the frequency of dementia in various groups. Among those 65 or over, approximately 6% can be expected to suffer from severe dementia, and another 10% to 15% evidence mild to moderate impairment.

The frequency of dementia, not surprisingly, increases with age. The percentage of demented individuals can be expected to double for each five-year increment in age, so that about 20% of those over age 75 will show severe symptoms of dementia.

Dementia should be expected to appear more frequently in more restrictive medical facilities, and that expectation is borne out by the research. About 54% of state hospital patients demonstrate severe dementia, while 30% of nursing home residents and 15% of retirement community residents are severely demented. Mild dementia (or worse) can be expected in 94% of state hospital patients, 87% of nursing home residents and 80% of retirement community residents.

What do these figures mean for the treatment or care of demented patients? The high frequency of dementia other than Alzheimer’s Disease suggests the importance of differential diagnosis of dementing illnesses. While most dementia is irreversible, some (such as metabolic conditions and infection) may be treated, and the progress of others (notably vascular dementia) may be slowed by drug therapy and/or diet. And diagnosis and treatment regimens become more important with age and type of treatment facility.

Long Term Care Insurance: A Primer and Review


Almost half of those reaching age 65 in any given year are expected to spend at least some time in a nursing home during the last years of their lives. With nursing home costs in Arizona averaging as much as $35,000 to $40,000 per year, few can afford sustained long term care costs. Medicaid, the federal program which has paid those costs for most patients, is likely to be extensively revamped (and curtailed) in this budget year.

All of that is the rationale for a tremendous growth in sales of long-term care insurance in recent years. While millions of Americans have purchased policies since they became widely available a decade ago, many are uncertain of the value of those policies.

In a rapidly-developing industry, the only completely predictable element is change. The most recent innovation is development of a long term care policy based on life insurance. With such a policy, the purchaser who never enters a nursing home will have left a substantial payment to beneficiaries at death, while providing coverage in the event that nursing home placement becomes necessary.

The principal drawback to life-insurance-based long term care policies is cost. Since the policy also includes a death benefit, it stands to reason that the expense will be higher.

Purchasers of long term care insurance (whether or not they are considering one of the new kinds of policies) should be alert to common shopping pitfalls:

  • Length of coverage–current Medicaid rules impose a three-year penalty on asset transfers by the applicant. If the purpose of insurance is to permit transfer of assets (to children, for example), then coverage should extend for more than the three-year period. Given upcoming changes and a desire for flexibility, the prudent purchaser should opt for five years of coverage.
  • Home care–any good policy should provide coverage for assistance in the home. One item to look out for: “Activities of Daily Living” should include ability to bathe oneself. Otherwise, someone with limited deficits may need assistance but fail to qualify for in-home help.
  • Inflation protection–nursing home care costs tend to increase faster than inflation. Some policies permit periodic purchase of increased protection. Some life-insurance based products rely on increased policy value to make up future differences between cost and benefit.

Elderly Suicide Rate Increases

The suicide rate among elderly Americans is rising after decades of decline. That’s the conclusion of a federal study released last week that cites depression, alcohol abuse, social isolation and physical illness as leading risk factors.

The Centers for Disease Control and Prevention said the suicide rate for those 65 and older increased by nine percent between 1980 and 1992. The suicide rate for the elderly had declined from the 1940s until 1980, when it began to increase, the CDC said. The biggest suicide rate increase occurred among the 80-to-84 age bracket, while the rate declined among adults aged 65 to 74.

ECT Treatment Considered by Courts In Two States


Two recent cases involved the availability and use of electroconvulsive therapy (ECT), with different results. Since Arizona appeals courts have not ruled on the use of ECT, the different conclusions of these recent decisions may be instructive in analyzing the use of ECT in Arizona.

ECT is, as most clinicians know, one of the most reviled and misunderstood therapies available to modern psychiatric medicine. Although most lay people believe they have some familiarity with ECT, few know more than the impressions they gained from such depictions as One Flew Over the Cuckoo’s Nest. While ECT is utilized as a treatment of last resort in most cases, it may be tremendously effective for dealing with some illnesses, particularly depression, after conventional drug therapy has failed.

ECT has been legally banned in some localities, and has been the subject of public demonstrations and intense political pressure in many jurisdictions. As administered today, however, the procedure is relatively safe and frequently offers relief where no other therapy is helpful.

In Illinois, Lucille Austwick admitted herself to a psychiatric unit specializing in geriatric patients. She was diagnosed as suffering from chronic depression and dementia. Physicians recommended that she be treated with ECT, insisting that her life was otherwise in danger. Her guardian (the Illinois equivalent of the Public Fiduciary’s office) sought emergency court approval for the treatment.

The trial court hearing Ms. Austwick’s case found that she lacked capacity, that there was no evidence whether she would have approved the ECT if she were able to communicate, and that the treatment was in her best interests. On review, the appellate court agreed that she lacked capacity and that the question should be whether the treatment was in her best interests. Citing the dangerous nature of ECT and specifically finding ambiguity in one physician’s testimony, however, the appellate court found the trial court’s decision “manifestly erroneous” and barred the ECT treatment. Austwick v. Legal Advocacy Service, Ill. App. Ct., 9/7/95).

In Wisconsin, meanwhile, in a case strikingly similar, the court reached the opposite conclusion. Ruth E.J. was severely depressed, and physicians told her guardian that ECT was the only hope for treating her depression. Wisconsin law dictates that ECT may be administered only with the patient’s “express and informed consent,” notwithstanding that Ruth E.J. was incompetent to give such consent.

Ms. E.J.’s guardian, like Ms. Austwick’s, brought an action for court approval of the ECT. The Wisconsin court, however, reacted quite differently; finding that the statute as applied to Ms. E.J. was unconstitutional, the court ruled that ECT may not be withheld from a patient simply because they lack capacity to give specific consent. In re Guardianship of Ruth E.J. v. Ruth E.J., Wis. Ct. App., 9/6/95).

Euthanasia Down Under

MAY 29, 1995 VOLUME 2, NUMBER 47

What state legislative body is the first to adopt a formal mechanism for permitting physicians to participate in the suicide of terminally ill patients? If you answered Washington or Oregon, you are wrong. If you broadened the definition of “state” and answered The Netherlands, you are still wrong.

Last week The Northern Territory, Australia (Capital: Darwin), by a 15-10 vote, became the first state with a legislatively-adopted provision which permits voluntary euthanasia. The new law is effective only when the following circumstances are met:

  • the patient must be over age 18, competent and suffering from extreme pain for which no further pain control measures are available.
  • the patient must initiate the request, and then wait seven days.
  • two doctors (one of whom must have psychiatric credentials) with at least five years experience each must certify that the patient is terminally ill and beyond medical help.
  • the doctors may not be related to one another by blood or business dealings.
  • both doctors must agree that the patient is not clinically depressed, and that he knows the effect of his decision on his family.

The new law does not specify the method of euthanasia which may be employed, but provides for adoption of regulations governing such questions.

Technically, the national government of Australia has the power to disallow the Northern Territory’s new law. Although the power is part of Australia’s constitutional framework, it has never been exercised before and observers do not expect it to be utilized in this case.

Although “physician-assisted suicide” has been adopted in Oregon, it was done by a voter referendum. Washington State’s year-old law was based on a federal court case declaring the prohibition of physician-assisted suicide to be unconstitutional. In The Netherlands euthanasia remains technically illegal, but the prosecutor’s office has adopted guidelines under which no prosecution will be mounted.

Elderly Living Alone

Elderly Americans are increasingly likely to be living alone, according to a newly-released survey. While 7.3% of seniors lived alone in 1960, over 30% were doing so by the late 1980s.

At least part of this growth phenomenon has been attributed to increasing divorce rates. Still, the largest force in the growth of the elderly living alone is the fact that women outlive their spouses by an average of nearly 7 years, coupled with the aging of the population.

Analysts predict that this continuing trend should result in dramatic increases in demand for assisted-living and home-based services.

More AZ White House Conference on Aging


As mentioned in last week’s Elder Law Issues, the Arizona White House Conference on Aging held in Phoenix a week ago dealt with the issues facing the full White House Conference on Aging when it meets in May. Arizona’s delegation dealt with several issues expected to dominate the national aging agenda.

Health Care and Mental Health

In 1993, expenditures for health care totaled about $903 billion in the United States. Estimates indicate that the total cost of health care may exceed $1.7 trillion by the year 2000. While the overall cost of living increases at less than 5% per year, health care costs increase more than 10% each year.

Elderly citizens are more closely affected by medical problems than the general population. Those over 65 have an average of eight medical visits per year, as opposed to the five visits made by the rest of the population. The elderly are hospitalized more than three times as often as younger patients, stay half again as long in the hospital, and use twice as many prescription drugs. The disparity is widening; elderly patients are expected to increase their contacts with physicians by 22% (from 259 million contacts to 296 million) by the turn of the century.

The federal Medicare program provides medical care to most Americans over age 65 (about 5% of the elderly are not covered by Medicare). In 1995, Medicare recipients pay $46.10 per month(an increase of over 10%) in insurance premiums to secure coverage for most medical care. Costs not covered by Medicare include eye and dental care, most prescription medications, most nursing home care and most mental health care.

In addition to Medicare Part B premiums, many elderly patients pay substantial deductibles and co-payments for their medical coverage. Others (in increasing numbers) rely on managed care (HMO) programs to reduce or eliminate co-payments.

Mental health services are particularly limited by Medicare. While Arizona has one of the highest suicide rates for over-65 patients in the nation, depression and alcoholism (the leading precursors to suicide and other behavioral health problems) are often undetected and untreated. Reimbursement rates and coverages are not conducive to appropriate and prompt treatment.

Elderly patients in rural areas face particular problems with health care. In addition to the other health issues, rural Arizonans have particular difficulties with transportation. In addition, physicians in rural areas are much more likely to refuse to accept Medicare assignment for their services.

[Next issue: “Special” Elderly Populations]

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