The Hospital Is No Place for the Elderly (1st of 3 installments)

https://www.theatlantic.com/magazine/archive/2013/12/the-home-remedy-for-old-age/354680/

Medical treatment for aging, chronically ill patients is costly and often ineffective. Can they get better care at home?

By JONATHAN RAUCH, DECEMBER 2013 ISSUE of HEALTH

It is 1976. Brad Stuart is in his third year of medical school at Stanford, doing his first clinical rotation. He is told to look at an elderly man with advanced lymphoma. The patient is feeble and near death, his bone marrow eviscerated by cancer. The supervising oncologist has ordered a course of chemotherapy using a very toxic investigational drug. Stuart knows enough to feel certain that the treatment will kill the patient, and he does not believe the patient understands this. Like a buck private challenging a colonel, he appeals the decision, but a panel of doctors declines to intervene. Well, Stuart thinks, if it must be done, I will do it myself. He mixes the drug and administers it. The patient says, “That hurts!” A few days later, the man’s bed is empty. What happened? He bled into his brain and died last night. Stuart leaves the room with his fists clenched.

To this day, he believes he killed the patient. “I walked out of that room and said, ‘There has got to be a better way than this,’ ” he told me recently. “I was appalled by how we care for—or, more accurately, fail to care about—people who are near the end of life. We literally treat them to death.”

Here is a puzzling fact: From 1970 until 2009, spending on health care in this country rose by more than 9 percent annually, creating fiscal havoc. But in 2009, 2010, and 2011, health-care spending increased by less than 4 percent a year. What explains the change? The recession surely had something to do with it. But several recent studies have found that the recession is not the whole story. One such study, by the Harvard University economists David Cutler and Nikhil Sahni, estimates that “structural changes” in our health-care system account for more than half of the slowdown.

In a sense, Brad Stuart is one of those changes. He is a leader in a growing movement advocating home-based primary care, which represents a fundamental change in the way we care for people who are chronically very ill. The idea is simple: rather than wait until people get sick and need hospitalization, you build a multidisciplinary team that visits them at home, coordinates health-related services, and tries to nip problems in the bud. For the past 15 years, at Sutter Health, a giant network of hospitals and doctors in Northern California, Stuart has devoted himself to developing home-based care for frail, elderly patients.

For years, many people in medicine have understood that late-life care for the chronically sick is not only expensive but also, much too often, ineffective and inhumane. For years, the system seemed impervious to change. Recently, however, health-care providers have begun to realize that the status quo is what Stuart calls a “burning platform”: a system that is too expensive and inefficient to hold. As a result, new home-based programs are finally reaching the market, such as one launched about five years ago at Sutter, called Advanced Illness Management. “It’s much more feasible now to make a program like this work than it was a few years ago,” Stuart told me. “There are a lot of new payment schemes in the pipeline that are going to make this kind of program much easier to support.”

This is good news. Generalizing from a small sample is always perilous, but if what is happening at Sutter is any indication, a more humane, effective, and affordable health-care system is closer than we think.

The problem that home-based primary care addresses has been well understood for years. Thanks to modern treatment, people commonly live into their 70s and 80s and even 90s, many of them with multiple chronic ailments. A single person might be diagnosed with, say, heart failure, arthritis, edema, obesity, diabetes, hearing or vision loss, dementia, and more. These people aren’t on death’s doorstep, but neither will they recover. Physically (and sometimes cognitively), they are frail. Joanne Lynn, the director of the Altarum Institute’s Center for Elder Care and Advanced Illness, says that this “frailty course,” a gradual and medically complicated downslide, was once exceptional but is now the likely path for half of today’s elders.

Seniors with five or more chronic conditions account for less than a fourth of Medicare’s beneficiaries but more than two-thirds of its spending—and they are the fastest-growing segment of the Medicare population. What to do with this burgeoning population of the frail elderly? Right now, when something goes wrong, the standard response is to call 911 or go to the emergency room. That leads to a revolving door of hospitalizations, each of them alarmingly expensive. More than a quarter of Medicare’s budget is spent on people in their last year of life, and much of that spending is attributable to hospitalization. “The dramatic increase in costs in the last month of life is largely driven by inpatient hospital stays,” Helen Adamopoulos recently reported on MedicareNewsGroup.com. “On average, Medicare spends $20,870 per beneficiary who dies while in the hospital.”

Hospitals are fine for people who need acute treatments like heart surgery. But they are very often a terrible place for the frail elderly. “Hospitals are hugely dangerous and inappropriately used,” says George Taler, a professor of geriatric medicine at Georgetown University and the director of long-term care at MedStar Washington Hospital Center. “They are a great place to be if you have no choice but to risk your life to get better.” For many, the worst place of all is the intensive-care unit, that alien planet where, according to a recent study in the Journal of the American Medical Association, 29 percent of Medicare beneficiaries wind up in their last month of life. “The focus appears to be on providing curative care in the acute hospital,” an accompanying editorial said, “regardless of the likelihood of benefit or preferences of patients.”

Taler can attest to one of the more peculiar elements of this situation, which is that a better model—namely, providing care and support at home—has been known and used for decades. Taler himself pioneered an interdisciplinary house-call model in Baltimore in 1980, and in 1999 he co-founded a home-based primary-care program at Washington Hospital Center that has served almost 3,000 people. In the 1970s, the Veterans Administration (now the Department of Veterans Affairs) began building a home-based primary-care program, which now operates out of nearly every VA medical center and serves more than 31,000 patients a day. This is not newfangled, untested stuff.

Should Patients With Dementia Be Able To Decline Spoon-Feeding?

Republished from: https://www.npr.org/sections/health-shots/2017/11/03/561393940/should-dementia-patients-be-able-to-decline-spoon-feeding

November 3, 2017

By JONEL ALECCIA
FROM Kaiser Health News

People who abhor the thought of being kept alive with feeding tubes or other types of artificial nutrition and hydration have, for years, had a way out: They could officially document their wishes to halt such interventions using advance directives.

Even patients diagnosed with progressive dementia who are able to record crucial end-of-life decisions before the disease robs them of their mental capacity could write advance directives.

But caregivers and courts have rarely honored patients' wishes to refuse food and fluids offered by hand.

Margot Bentley, 85, of British Columbia, died last year. She was a retired nurse who had cared for dementia patients before being diagnosed with Alzheimer's in 1999. In 1991, she wrote a statement stipulating that she wanted no nourishment or liquids if she developed an incurable illness. However, the nursing home where she was a patient continued to spoon-feed her, despite her family's protests. A court ruling upheld the nursing home's action, saying that food is basic care that cannot be withdrawn.

Nora Harris, 64, of Medford, Ore., died on Oct. 11 after an eight-year struggle with early-onset Alzheimer's disease. More than a year earlier, her husband had gone to court to stop caregivers from spoon-feeding Harris, who had an advance directive that called for no artificial nourishment or hydration. A judge declined, siding with officials who said the state was required to feed vulnerable adults.

To try to reverse this trend, a Washington state agency that advocates for medical aid-in-dying has created guidelines for dementia patients who don't want to be spoon-fed at the end of life.

The group End of Life Washington, or EOLWA, which assists people using the state's 2009 Death with Dignity Act, recently posted a guide called Instructions for Oral Feeding and Drinking on its website.

Aimed at people with Alzheimer's disease and other progressive dementias, the document provides a two-page template for patients to instruct caregivers not to provide oral food or fluids under certain circumstances. There's another document explaining the do's and don'ts of using it.

The instructions are ground-breaking for patients who fear losing control not only of their faculties but of their free will to live and die on their terms, says Sally McLaughlin, executive director of EOLWA.

"We get calls from folks with concerns about dementia and concerns about the fact that loved ones with dementia feel like they're being force-fed," McLaughlin says. "Many, many folks understand that as they stop eating, they would like no one else to feed them."

Critics say the new document raises concerns about potential mistreatment of vulnerable patients, arguing that such "instructions" could be used essentially to starve the elderly or incapacitated.

"It really is troubling," says Stephen Drake, research analyst for the disability rights group Not Dead Yet.

He points to other so-called right-to-die efforts, such as the refusal of artificial nutrition and hydration, saying they started out narrowly defined and then became common practice.

"It really is a big game changer in the number of people whose lives can be ended when they're in vulnerable situations," Drake says. "In legal situations, this is a door-opener."

Proponents of the guidelines say they fill a gap in information for people already interested in navigating the uncertain landscape that surrounds assisted feeding at the end of life.

"What we are saying is that there are objective and somewhat subjective conditions in the future where you can say 'I'm giving you instructions now to help you interpret my wishes,' " says Bob Free, a Seattle lawyer who helped draft the document. "We have never really seen a standard form or advance directive to govern this."

The guidelines do not apply to people with dementia who still get hungry and thirsty and want to eat and drink, the authors note.

"If I accept food and drink (comfort feeding) when they're offered to me, I want them," the document states.

But if the person appears indifferent to eating, or shows other signs of not wanting food — turning away, not willingly opening their mouth, spitting food out, coughing or choking — the document says attempts to feed should be stopped.

And the guidelines tell caregivers to respect those actions.

"No matter what my condition appears to be, I do not want to be cajoled, harassed or forced to eat or drink," the document states. It adds that the "reflexive opening" of the mouth should not be interpreted as consent to eating.

"We think this is a fairly objective test, which in real life will be clear," says Free.

The new guidelines aren't binding, legally or ethically, experts say. Nearly two dozen states have laws that address assisted feeding, including many that prohibit withdrawing oral food and fluids from dying people.

"The hard part about advance directives is even though you put your wishes there, it doesn't mean a medical professional will honor it, or that a facility will honor it," says Jonathan Patterson, staff attorney for Compassion and Choices, a group that supports medical aid-in-dying. But having a template should help make those wishes more clear.

Cases like Harris' and Bentley's horrify people who fear the same fate. Nancy Christensen, 60, a Seattle nurse, says she updated her living will herself within days of reading about Harris.

"I thought, 'Wow, I need to be much more specific,' " says Christensen, who appended notes saying she doesn't want assisted feeding if she can no longer feed herself. "I don't think anybody thinks about this until they're too far into it."

Free, 71, says he plans to fill out the new documents himself.

"It's been a personal desire of mine to have a dignified death," he says. "The idea that my sons would have to witness me in a deteriorated state is very frightening and demoralizing."

Whether the decision to voluntarily stop eating and drinking can be authorized in advance by people diagnosed with dementia remains unclear. The question has gained traction in a nation where dementia cases in people 65 and older are projected to reach 7.1 million by 2025.

Paul Menzel, a bioethicist and professor emeritus at Pacific Lutheran University in Tacoma, Wash., says some people want to avoid the most debilitating stages of the disease. "It's not misery they're afraid of," he says. "They just don't want years of withering."

The End Of Life Washington document is a novel tool, but it may not go far enough, says Judith Schwarz, clinical director for End of Life Choices New York, which advocates for medical aid-in-dying. The conditions it lists typically apply to the final stages of dementia, she says. Some patients want the right to refuse food earlier in the disease process in a deliberate effort to hasten death.

Until now, however, there have been few models for articulating those desires.

"It certainly is an improvement over no previous mention of hand-feeding," Schwarz says. "Maybe this is where it must begin."

JoNel Aleccia covers aging and end-of-life care at Kaiser Health News. Reach her on Twitter at @JoNel_Aleccia.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

KHN's coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation and its coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.

Caregiving Is Hard Enough. Isolation Can Make It Unbearable.

Many caregivers find themselves trapped at home, neglected by friends and family members who don’t understand how to help.

By Paula Span
THE NEW OLD AGE AUG. 4, 2017

For years, Marcy Sherman-Lewis went to a beauty salon in St. Joseph, Mo., every few weeks for a haircut and highlights.

It had become something of an ordeal to prepare her husband, Gene Lewis, for this outing; he has Alzheimer’s disease, at 79, and helping him shower and dress, insert hearing aids and climb into the car was a very slow process.

But she could no longer leave him at home alone. And once at the salon, “he just sat, watched TV, slept — didn’t bother anybody,” said Ms. Sherman-Lewis, 62. Her stylist kindly trimmed his hair, too.

Then last month, the salon owner took Ms. Sherman-Lewis aside. “Marcy, he makes my other patrons awfully uncomfortable,” she said.

“I was dumbfounded,” Ms. Sherman-Lewis said. “It’s O.K. for other people’s little grandchildren to be running around sometimes. What am I supposed to do, keep him in a crate in the car?”

Like so many caregivers, she has discovered that along with the abandoned career, the hands-on tasks, the medical scheduling, the insurance tussles and the disrupted sleep, she faces another trial: social isolation.

“It’s hurtful,” she said. “You need friends more than ever.”

But where are they? Betsey Brairton, 48, cares for her mother, Sue, in rural Olean, N.Y. The elder Ms. Brairton, 79, suffers from spinal stenosis, arthritis and lingering damage from a stroke, so she has limited mobility. “We hardly go anywhere, and nobody comes here,” said her daughter. When she does leave for an hour or two, she’s afraid to put down her cellphone.

Though a couple of friends occasionally invite her out for dinner, “I can’t commit to anything, in case my mom is having a bad day,” Ms. Brairton said. She has begun to worry that when she does spend time with others, her narrowing life leaves her with nothing interesting to say.

Those who work with caregivers know this phenomenon well, especially when the cared-for person has dementia, a particularly arduous responsibility.

“Caregiving is done with a lot of love and affection, but there’s a lot of loss involved,” said Carey Wexler Sherman, a gerontologist at the University of Michigan Institute for Social Research. “People talk about friends disappearing, about even family members not wanting to be involved. It’s a lonely business.”

Sometimes, caregivers isolate themselves. Barbara Moscowitz, senior geriatric social worker at Massachusetts General Hospital, hears clients lament that with a loved one whose dementia-related behavior can be startling, venturing out in public creates more apprehension than pleasure.

“They say, ‘I’m exhausted trying to explain to people why she’s doing what she’s doing, why they shouldn’t be angry or afraid,’” Ms. Moscowitz said. “It’s just easier to stay home.”

Yet a habit of avoiding others — or watching them avoid you — collides with a growing body of research showing how damaging isolation and loneliness can be. They are associated with a host of ills, including heart disease and stroke. Among older people, isolation is linked to depression, even higher mortality. Lonely old people, Dutch researchers have found, are more apt to develop dementia.

We’ve long thought of these factors as dangers for the people being cared for. But they also imperil caregivers, who are often older adults as well.

Years of caring for his wife, now deceased, who had early onset Alzheimer’s, left Les Sperling, 65, so despondent that “I’d stay in my room in the dark and sleep all day,” he said. “I didn’t want to come out.”

Mr. Sperling, of Lake Worth, Fla., went into therapy and took antidepressants until he felt able to function again.

We know something about how to help caregivers feel less alone. Researchers have shown that even modest-sounding interventions can reduce their sense of isolation and improve their mental and physical health.

Mary Mittelman, director of the Alzheimer’s Disease and Related Dementias Family Support Program at NYU Langone Health, has been conducting such studies for years.

With federal and state grants, the program — involving several counseling sessions, followed by support groups and phone access to counselors as needed — has inspired others that have been adopted throughout New York and in several other states.

“The support is what leads to less stress, less depression, better health and delayed nursing-home admissions,” Dr. Mittelman said. Interestingly, her team has found that “instrumental support,” in which others actually help with tasks, has less impact than emotional support.

“Having someone outside who is paying attention and who cares is more important,” she said.

Other initiatives, like Savvy Caregiver and REACH, have demonstrated similar effectiveness. Because they are offered under various names in different states, Area Agencies on Aging can help besieged caregivers find free local programs. And since getting out of the house can be a struggle, program developers are also testing online versions.

Caregivers already gather in Facebook groups and on websites, but experts have mixed feelings about online chats and groups. “They provide anonymity, and that may permit more honesty,” said Dr. Wexler Sherman, the gerontologist. “Sometimes you need to vent at 2 a.m.”

”But we need skills,” she said. “Being a caregiver is a job.” Online, is the information passed along accurate and useful? Is there a trained, knowledgeable moderator?

“It’s important to have a leader to monitor and validate,” said Ms. Moscowitz, who leads several support groups for Mass General employees and for community members. Besides, “there’s nothing like a real person to hug you.”

On other fronts, we’re seeing more efforts to provide convivial social and cultural events for both people with dementia and their caregivers: Memory Cafes, museum programs, choruses. The Dementia Friendly America campaign aims to make whole communities — including police forces, churches, restaurants and hair salons — more knowledgeable and accommodating.

Individuals can also play a role. It’s too easy to let caregiving friends slip off our radar with a general call-if-you-need-anything.

“Don’t put the pressure on the caregiver to tell you what to do,” Ms. Moscowitz said. She suggests asking what would be helpful, making a list of specific tasks and parceling out assignments.

“Don’t invite me for lunch — you know I can’t go,” Ms. Sherman-Lewis said. “Just bring a pizza and a bottle of wine and come by.”

Though tangible help counts — and let’s acknowledge that an aging country can’t rely solely on families, friends and volunteers to provide everything dependent elders need, however well supported they are — so do regular texts, calls or visits. They help keep caregivers from feeling invisible and forgotten.

Counselors in the NYU program once had the friendly inspiration, since they kept caregivers’ information in their database, to send clients a card on their birthdays.

It sounds sweet, if trivial. But often, Dr. Mittelman said, “they’d call up, so grateful, and say, ‘You’re the only one who remembered.’”

Reprinted from: https://www.nytimes.com/2017/08/04/health/caregiving-alzheimers-isolation.html?smprod=nytcore-ipad&smid=nytcore-ipad-share

Elder Care and Assisted Living: Who Will Care for You? (Part III)

Protections Consumers Need

Consumer Reports recommends these 6 steps to improve care in assisted living.

It’s clear that the assisted living industry needs to evolve to manage the increasing health needs of the population it aims to attract. In that vein, more federal and state regulatory oversight is urgently needed to protect residents and their families. CR believes policy makers should better protect consumers of assisted living facilities by doing the following:

1.       Define Assisted Living and Levels of Care
The term “assisted living” can describe anything from a facility that merely offers room and board to one that provides full-time nursing care. As a result, confused consumers can end up paying for services they don’t need or, worse, not getting the care they do need. Policy makers should establish and clearly define level-of-care classifications, and facilities should be required to use the classifications to communicate the assisted living services they offer.

2.       Set Staffing and Training Standards
Staff training and qualification requirements, and minimum per-resident staffing levels, should be set according to level-of-care classifications. Qualified, licensed medical staff should monitor the overall health of residents and administration of medications. Special staffing requirements should be established for residents with high-level care requirements, including residents with dementia.

3.       Establish Resident Rights
Policy makers should establish a comprehensive Bill of Rights to ensure some basic rights for residents, including the right to make everyday decisions; receive visitors at any time; refuse treatment; access and control their own money; question and object to facility practices and policies; make formal complaints to administrators and regulators; and bring lawsuits seeking court orders to stop illegal activities and violations and to compensate residents for rights, standards, or contractual violations (a right that should prevail even when residents have signed forced-arbitration clauses, which should be restricted).

4.       Support Aging in Place
Policy makers should narrow the number of allowable reasons for evicting residents. Reasonable accommodations should be made, when possible, to allow a resident to remain in a facility, and all services allowable under a resident’s level-of-care designation should be made available. If a resident who initially paid privately goes on Medicaid and resides in a Medicaid-certified facility, that facility should be required to accept Medicaid reimbursement for that resident.

5.       Enforce Regulations
Policy makers should establish rules requiring inspections tied to levels of care. Penalties for violations should be strengthened and applied on a per-violation and per-day basis.

6.       Make Price and Quality Information Transparent
Policy makers should establish a system that enables consumers to compare costs, features, and services across facilities and types of facilities, including information related to facility inspections and disciplinary actions.

Editor’s Note: This article also appeared in the October 2017 issue of Consumer Reports magazine.

Blog reprinted from article called: Elder Care and Assisted Living: Who Will Care for You? By Penelope Wang, August 31, 2017, https://www.consumerreports.org/elder-care/elder-care-and-assisted-living-who-will-care-for-you/

Elder Care and Assisted Living: Who Will Care for You? (Part II)

10 Helpful Resources

Finding information about assisted living residences in your area will require some digging. Online resources can speed your search. You can also enlist expert help that can save time and avoid costly mistakes.

For an Overview of Senior Housing Options: AARP
Comprehensive information on independent living and nursing homes, as well as assisted living.

To Start Your Search for an Assisted Living Facility: Caring.com
Click Assisted Living, then enter your ZIP code to find residences; listings include communities and services with current state licensing.

If You’re in a Hurry to Find a Residence: A Place for Mom
This referral service is free to consumers; providers pay the site a fee if you move in.

To Get Help From an Aging-Life-Care Expert: Aging Life Care Association
Click on Find an Aging Life Care Expert to search in your state.

To Check the Assisted Living Regulations in Your State: National Center for Assisted Living
Go to Advocacy, then State Regulations to see rules for every state.

A Starting Point for Checking Assisted Living Violations: A Place for Mom
Click on your state to find out how to obtain inspection reports.

To Contact Your State Long-Term-Care Ombudsman
National Long-term Care Ombudsman Resource Center

Use the map tool to locate links for your state.

To Get a Legal Review of Your Contract
National Academy of Elder Law Attorneys

For the Basics on Long-Term-Care Benefits
LongTermCare.gov
This federal website provides an overview of long-term care, as well as links to Medicare and Medicaid information.

For First-Person Insight Into Assisted Living
The Thin Edge of Dignity
Dick Weinman, a retired professor of broadcast communications at Oregon State University, became wheelchair-bound in 2005 after a car crash. In this short documentary, he describes his personal experience with assisted living and how he manages to stay active.

Blog reprinted from article called: Elder Care and Assisted Living: Who Will Care for You? By Penelope Wang, August 31, 2017, https://www.consumerreports.org/elder-care/elder-care-and-assisted-living-who-will-care-for-you/

Elder Care and Assisted Living - Who Will Care For You? Part 1

Making the Right Moves

Despite these challenges, families can find high-quality assisted living facilities. But start your search well before you or your parent actually needs care. If your parent’s health declines, assisted living might not even be an option, says Deborah Fins, an aging-life-care expert in Worcester, Mass. Many facilities will not take people who are wheelchair-bound or need help with multiple chronic conditions, but some allow residents to stay if they become more infirm. To help you target your search, here are four key questions to ask:

1. What Kind of Help Will the Resident Need?

Perhaps your parent no longer drives and is becoming socially isolated. Or he or she can’t manage stairs or forgets to turn off the oven. For seniors who need moderate amounts of support, assisted living could be the smart choice. Assisted living is working well for Sharon Koenig, 76, who lived alone for two years after her husband died. “I kept waiting for him to come in the door,” Koenig says. She also was having trouble tracking her medications. With help from an aging-life-care expert, who is familiar with local facilities, Koenig looked at several senior residences, including a small nursing home.

Unlike some of the other places, Regal Palms in nearby Largo, Fla., a large facility with several levels of care, offered a varied menu of activities. Last October, Koenig moved to the assisted living section, into a two-bedroom apartment that has space for her 50-gallon aquarium. She gets help with medication but still does her own laundry. “Some people might be afraid of a big place, but I think it’s better,” she says. “There’s always someone to have dinner with.”

Smart move: Make sure your family member has a medical evaluation from a primary care doctor—or a specialist, if your parent has an illness—to understand the level of care required, as well as how those needs might change. For more perspective, hire an aging-life-care expert to help point you to appropriate residences. “Given the wide variation in the types of services provided by assisted living communities, it’s well worth spending the several hundred dollars for a professional care manager,” says Stephen Maag, a director at LeadingAge, an association of nonprofit senior-living groups.

2. How Good Is the Quality of Care?

Make sure the residence is licensed to provide assisted living, to ensure that there’s at least a minimum level of oversight. Take a close look at the residence’s inspection record, which indicates how often it has been checked or whether it has had complaints. (See “10 Helpful Resources,” below.) Some states, such as Florida and California, maintain consumer-friendly assisted living websites that list inspection records and regulatory actions. But some states do not, or they fail to update them. You can also ask your state ombudsman’s office about a facility’s complaint record.

In the end, the best information about quality of care could come from people who visit facility residents, as well as from the residents themselves. Ask the residents specifics about the care—whether meds are delivered on time, for example—and how management responds to complaints, suggests Liz Barlowe, an aging-life-care expert in Seminole, Fla.

Try to make multiple visits to the residence—including at meal time and on weekends. Most facilities will welcome you even if you don’t have an appointment. Talk to residents, and see whether the staffers seem happy or appear overworked.

Smart move: Ask how the residence would handle a fall, a common occurrence. Would a nurse be on hand to evaluate your parent, or would he be sent to the emergency room? And ask whether “the facility provides an on-site clinician or medical staff that can help the resident avoid the expense and health risk of an unnecessary trip to the ER or a hospitalization,” says Alan Kronhaus, M.D., CEO of Doctors Making House Calls, a North Carolina medical group that provides on-site healthcare to assisted living residents.

3. What Are the Real Costs of Care?

Ask for a written list of the fees, and make sure the information is included in your contract. (See “Putting Your Contract Under the Microscope.”) Some facilities have all-in costs that cover room, board, and care for a particular level of assistance, and others have point systems or charge à la carte. (See “11 Ways to Afford the Care You Need.”)

Be sure to get clear information about the circumstances that could trigger higher or additional charges and how the facility assesses those fees, says Patty Ducayet, state long-term-care ombudsman for Texas. What would it cost to have your dad driven to a doctor 10 miles away vs. 5 miles away? Is it okay to hire private aides?

Smart move: Ask about the policy for lowering fees. Say your mom requires a higher level of care for a week to recover from a hospital stay. How quickly can the fees be cut when she has recovered? “Bumping down the charges tends to take longer than bumping up,” says Karen Jones, a state long-term-care ombudsman in San Luis Obispo, Calif.

4. Can Your Parent Be Kicked Out?

Involuntary discharges rank among the top complaints in most states, according to the National Consumer Voice survey. Discharges are usually triggered by lack of payment or care needs that exceed the facility’s capacity to provide the services. The discharge terms should be detailed in the contract, as well as the required amount of notice you’ll receive, which is typically 30 days.

For Jill Goldberg, the possibility of her mom’s discharge was unexpected. Her mom, Sylvia Wenig, 94, was living in Brookdale West Boynton Beach in Boynton Beach, Fla. “We’d been getting great care there,” says Goldberg, 61, who lives near Boston. But after a hospitalization, Wenig lost her mobility and was not allowed to return to the facility. Goldberg asked if her mother could return for a week or two to allow time to find another facility, but Brookdale refused.

Goldberg says she persuaded the hospital to let her mother stay a few more days, and with help from an aging-life-care expert, she moved Wenig to a nursing home. Says Brookdale spokesman James Hauge, “For residents who require more care than the community is able to provide, we inform them of other care options and actively help them find a community that can meet their new care needs.”

Smart move: Don’t rely on the marketing director’s assurances that your parent will be able to age in place. “Verbal agreements are nearly impossible to prove,” says Jones, who recommends getting the promises in writing. With assisted living, it’s better to know exactly where you stand.

Blog reprinted from article called: Elder Care and Assisted Living: Who Will Care for You? By Penelope Wang, August 31, 2017, https://www.consumerreports.org/elder-care/elder-care-and-assisted-living-who-will-care-for-you/

Living with Alzheimer's, As a Patient and a Caregiver

Reprinted from: http://www.wnyc.org/story/alzheimers/
Jul 23, 2015

More than five million Americans suffer from Alzheimer's disease, and according to the Alzheimer's Association, and 15.5 million Americans are currently caring for them.

A new drug might provide some hope for those showing very early symptoms of the disease. This week at the annual Alzheimer’s Association International Conference in Washington, the pharmaceutical company Eli Lilly released new data on a drug that seems to prevent the buildup of amyloid plaques in the brain—the type of plaques many doctors believe are tied to Alzheimer's.

Scientists say it's much too early to tell if the drug will make it to the market, but for those who care for Alzheimer's patients, the potential treatment offers at least a glimmer of hope for a disease with very few prospective cures on the horizon.

Dr. David Kramer was diagnosed with Alzheimer's in 2012 at the age of 56. He retired from his job as an emergency room physician and currently lives with his wife and caregiver in Florida. He says he’s cautiously optimistic about the new data from Eli Lilly.

“I have some preliminary optimism with the results, but I had an opportunity to read the paper on the study that was discussed and presented,” says Kramer. “The data is very, very preliminary, and there’s not any clear evidence from what I can see that this will have any long-term effect. But it’s way too soon to tell.”

Like Kramer, Meryl Comer is also watching with some hope. She has been an Alzheimer's caregiver for 20 years—her husband, a former research physician at the National Institutes of Health, was diagnosed with early-onset Alzheimer's at the age of 57.

Comer, who is also a journalist and author of the New York Times bestseller, “Slow Dancing with a Stranger: Lost and Found in the Age of Alzheimer's,” cares for her husband along with her mother, who also has Alzheimer’s disease.

“It’s promising, but premature, and people tend to read the headlines only—we’ll receive calls saying, ‘Good news, your problems are over,” she says. “They don’t understand the complexities of the disease. It’s easier to get to Mars than it is to find a disease-modifying therapy for a very complex issue like Alzheimer’s.”

Comer applauds pharmaceutical companies that are working to find treatments and cures for the disease, despite the many false starts and failed attempts that have already been made.

“We went through a phase where, after these failed trials, we were afraid that we would be abandoned at a time when the numbers are growing exponentially—44 million globally are suffering from the disease,” she says. “The other new hopeful part is there are 13 new therapeutic compounds, and four or five are disease modifying therapies. I stay close to the science, as do all advocates, because we are desperate for a disease-modifying therapy. Just give us five more years of quality of life—think what that might mean to an individual.”

Despite the excitement around the findings presented by Eli Lilly, the hope of a treatment for an Alzheimer’s is just that—a hope.

“While these may have potential, even after the phase three trials are done, you still do not know if the effects will be long lasting—whether the slowdown in the progression of the disease, if it actually does occur, will be consistent overtime,” Kramer says. “There’s a lot to learn.”

Even with all the uncertainty, Kramer says that he does not feel powerless in the face of his diagnosis. 

“I feel that it’s important for me to enjoy the time that I have now,” he says. “My wife and I focus on doing everything that we can now and enjoying life. There is a definite benefit in having an early diagnosis, as I was fortunate to have. I can then say, ‘Alright, I know what I’ve got, but I’m doing well now.’ As long as I can continue to do well and live well with the disease, I plan on doing that.”

But not all are so lucky. Comer says that many doctors are reluctant to give an early diagnosis of Alzheimer’s because there is no cure. She says that her husband was misdiagnosed for four years, with doctors saying that her husband’s condition might have been Lyme’s disease or depression.

“It’s insulting to families who are lost and confounded by behaviors, because behaviors are the first things that appear around the disease,” she says. “We have to [call for] an early diagnosis—give us a chance to live in the moment with our loved ones, don’t decide for us.”

An early diagnosis, Comer argues, helps families and those suffering with the disease to live fully, especially since the disease can progress at different speeds.

“Often you’re moving from crisis to crisis,” she says. “You really try to look at the successes—that he had a good day. The caregiver actually forgets who they are because you are so focused on protecting the dignity of the loved one who has the disease and of giving them their last ‘hurrah.’ That takes tremendous energy.”

Comer adds that this is the “biggest women’s issue since breast cancer” since women often outlive men, and the majority of caregivers are women, who are also much more likely to give up their careers for a loved one in need.

“I interact a lot with many, many people with dementia, and I tell you that the primary concern that all of us have is about the health and welfare of our caregivers,” Kramer adds. “I’m much more concerned about the impact of this disease on my wife than I am on myself.”

Click here to hear the entire story from NPR

One-third of dementia cases could be prevented, report says

Reprinted from: http://www.cbsnews.com/news/one-third-of-dementia-cases-could-be-prevented-alzheimers-report/?WT.mc_id=enews2017_07_31&utm_source=enews-aff-28&utm_medium=email&utm_campaign=enews-2017-07-31

By ASHLEY WELCH CBS NEWS July 20, 2017, 5:00 AM

One-third of cases of dementia worldwide could potentially be prevented through better management of lifestyle factors such as smoking, hypertension, depression, and hearing loss over the course of a lifetime, according to a new report.

Across the globe, about 47 million people were living with Alzheimer's and other forms of dementia in 2015. That number is projected to triple by the year 2050 as the population ages. Health care costs associated with dementia are enormous, with an estimated $818 billion price tag in 2015.

The new study, published in The Lancet and conducted by the first Lancet Commission on Dementia Prevention and Care, brought together 24 international experts to review existing dementia research and provide recommendations for treating and preventing the devastating condition.

"Dementia is the greatest global challenge for health and social care in the 21st century," lead study author Professor Gill Livingston, of University College London, told CBS News. "The purpose of the commission was therefore to address it by consolidating the huge strides and emerging knowledge as to what we should do to prevent dementia and intervene and care for people with dementia."

There is currently no drug treatment to prevent or cure dementia. But the report highlights the impact of non-drug interventions and identifies nine modifiable risk factors through various stages of life — beginning in childhood — that affect the likelihood of developing dementia.

To reduce the risk, factors that make a difference include getting an education (staying in school until over the age of 15); reducing high blood pressure, obesity and diabetes; avoiding or treating hearing loss in mid-life; not smoking; getting physical exercise; and reducing depression and social isolation later in life. About 35 percent of dementia cases are attributable to these factors, the analysis found. Removing them could then theoretically prevent 1 in 3 cases.

In contrast, finding a way to target the major genetic risk factor, a gene called the apolipoprotein E (ApoE) ε4 allele, would prevent less than 1 in 10 cases – or about 7 percent.

"There's been a great deal of focus on developing medicines to prevent dementia, including Alzheimer's disease," commission member Lon Schneider, M.D., a professor of psychiatry and the behavioral sciences at the Keck School of Medicine of USC, said in a statement. "But we can't lose sight of the real major advances we've already made in treating dementia, including preventive approaches." Schneider presented the findings at the Alzheimer's Association International Conference (AAIC) 2017.

Of the nine risk factors, the researchers identified the three most common ones that could be targeted for dementia prevention.

The first is increasing education in early life, which the report estimated could reduce the total number of dementia cases by 8 percent if all people worldwide continued their education until over the age of 15.

The researchers note that not completing secondary education could raise dementia risk by reducing what's referred to as "cognitive reserve." It's believed that education and other mentally stimulating tasks help the brain strengthen its networks so it can continue to function at a higher level even if it starts to decline later in life.

For the first time, the researchers also identified hearing loss as a major modifiable risk factor for dementia. They estimated that reducing hearing loss in mid-life could also reduce the number of dementia cases by 9 percent if all people were treated.

Livingston notes that research surrounding hearing loss and dementia is still in early stages and the link likely has something to do with the social isolation that can come with losing the ability to hear.

"They may work in similar ways as they reduce the chance of interactions and conversations, which are like exercise for the brain and enrich it and predispose to depression," she said.

It's not clear from medical research yet whether using hearing aids can counteract this risk.

Additionally, the researchers found the number of dementia cases worldwide could be reduced by 5 percent if all people stopped smoking. It's particularly important to stop smoking later in life, they say, to reduce neurotoxins and improve heart health, which in turn improves brain health.

Other interventions likely to reduce dementia rates include increased physical activity and treating high blood pressure and diabetes.

The study authors say the report can offer guidance on ways to reduce the risk of dementia throughout life and improve the care for those living with the disease.

"This includes providing safe and effective social and health care interventions in order to integrate people with dementia within their communities," Schneider said. "Hopefully this will also ensure that people with dementia, their families and caregivers, encounter a society that accepts and supports them."

It's important to note that lifestyle interventions will not delay or prevent all dementia cases. But the researchers say they are hopeful that the report will help shift more focus to concrete steps that can be taken to help avoid the disease.

"We hope that this report will feed into individual nations' dementia policies and public health strategies, be used by individual clinicians to inform and improve their practice, and through media publicity inform the general public of what they can do to help avoid dementia, which is the most feared illness in old age."

© 2017 CBS Interactive Inc. All Rights Reserved.

Aging parents: 8 warning signs of health problems

Concerned about your aging parents' health? Use this guide to gauge how your aging parents are doing — and what to do if they need help.

By Mayo Clinic Staff

As your parents get older, how can you be sure they're taking care of themselves and staying healthy?

When you visit your parents, consider the following questions:

1. Are your parents able to take care of themselves?

Pay attention to your parents' appearance. Failure to keep up with daily routines — such as bathing and tooth brushing — could indicate dementia, depression or physical impairments.

Also pay attention to your parents' home. Are the lights working? Is the heat on? Is the yard overgrown? Any changes in the way your parents do things around the house could provide clues to their health. For example, scorched pots could mean your parents are forgetting about food cooking on the stove. Neglected housework could be a sign of depression, dementia or other concerns.

2. Are your parents experiencing memory loss?

Everyone forgets things from time to time. Modest memory problems are a fairly common part of aging, and sometimes medication side effects or underlying conditions contribute to memory loss.

There's a difference, though, between normal changes in memory and the type of memory loss associated with Alzheimer's disease and other types of dementia. Are your parents' memory changes limited to misplaced glasses or an occasionally forgotten appointment? Or are the changes more concerning, such as forgetting common words when speaking, getting lost in familiar neighborhoods or being unable to follow directions?

3. Are your parents safe in their home?

Take a look around your parents' home, keeping an eye out for any red flags. Do your parents have difficulty navigating a narrow stairway? Has either parent fallen recently? Are they able to read directions on medication containers? When asked, do your parents say they feel safe at home?

4. Are your parents safe on the road?

Driving can be challenging for older adults. If your parents become confused while driving or you're concerned about their ability to drive safely, it might be time to stop driving.

5. Have your parents lost weight?

• Losing weight without trying could be a sign that something's wrong. Weight loss could be related to many factors, including:
• Difficulty cooking. Your parents could be having difficulty finding the energy to cook, grasping the tools necessary to cook, or reading labels or directions on food products.
• Loss of taste or smell. Your parents might not be interested in eating if food doesn't taste or smell as good as it used to.

Underlying conditions. Sometimes weight loss indicates a serious underlying condition, such as malnutrition, dementia, depression or cancer.

6. Are your parents in good spirits?

Note your parents' moods and ask how they're feeling. A drastically different mood or outlook could be a sign of depression or other health concerns.

7. Are your parents still social?

Also talk to your parents about their activities. Are they connecting with friends? Have they maintained interest in hobbies and other daily activities? Are they involved in organizations or clubs? If a parent gives up on being with others, it could be a sign of a problem.

8. Are your parents able to get around?

Pay attention to how your parents are walking. Are they reluctant or unable to walk usual distances? Have they fallen recently? Is knee or hip arthritis making it difficult to get around the house? Would either parent benefit from a cane or walker?

Issues such as muscle weakness and joint pain can make it difficult to move around as well. If your parents are unsteady on their feet, they might be at risk of falling — a major cause of disability among older adults.

Taking action

There are many steps you can take to ensure your parents' health and well-being, even if you don't live nearby. For example:

• Share your concerns with your parents. Talk to your parents. Your concern might motivate your parents to see a doctor or make other changes. Consider including other people who care about your parents in the conversation, such as other loved ones, close friends or clergy.
• Encourage regular medical checkups. If you're worried about a parent's weight loss, depressed mood, memory loss or other signs and symptoms, encourage your parent to schedule a doctor's visit. You might offer to schedule the visit or to accompany your parent to the doctor — or to find someone else to attend the visit. Ask about follow-up visits as well.
• Address safety issues. Point out any potential safety issues to your parents — then make a plan to address the problems. For example, your parents might benefit from using assistive devices to help them reach items on high shelves. A higher toilet seat or handrails in the bathroom might help prevent falls. If your parents are no longer able to drive safely, suggest other transportation options — such as taking the bus, using a van service or hiring a driver.
• Consider home care services. If your parents are having trouble taking care of themselves, you could hire someone to clean the house and run errands. A home health care aide could help your parents with daily activities, such as bathing. You might also consider Meals on Wheels or other community services. If remaining at home is too challenging, you might suggest moving to an assisted living facility.
• Contact the doctor for guidance. If your parents dismiss your concerns, consider contacting the doctor directly. Your insights can help the doctor understand what to look for during upcoming visits. Keep in mind that the doctor might need to verify that he or she has permission to speak with you about your parents' care, which might include a signed form or waiver from your parents.
• Seek help from local agencies. Your local agency on aging — which you can find using the Eldercare Locator, a public service of the Administration on Aging — can connect you with services in your parents' area. For example, the county in which your parents live might have social workers who can evaluate your parents' needs and connect them with services, such as home care workers.

Sometimes parents won't admit they need help, and others don't realize they need help. That's where you come in. Make sure your parents understand the problem and your proposed solution. Remind your parents that you care about them and that you want to help promote their health and well-being, both today and in the years to come.

Reprinted from: http://www.mayoclinic.org/healthy-lifestyle/caregivers/in-depth/aging-parents/art-20044126

Exercise at any Age, with any Chronic Condition (Part 3)

Steven C. Castle, MD

Republished from: http://www.aginglifecarejournal.org/exercise-at-any-age-with-any-chronic-condition/

What this Geriatrician learned from the Gerofit program

The following describes an exercise program, Gerofit, and its proven benefits for its participants. The Gerofit program was started by Dr. Miriam Morey at the Durham VA and for the past 30 years has successfully provided an exercise venue for older adults with chronic conditions (Morey MC, 2007). The program requires a referral from the primary care provider, with a chart review and telephone interview. Then baseline and quarterly Senior Fitness Test assessments (Rikli RE 2013) tell you your percentile ranking by gender and five year age group.  This allows a prescribed individualized exercise program that includes exercises for aerobic/cardio, weight resistance, and balance.  Program participants demonstrated a 25% reduction in mortality over five years, and in a related study, those that showed a 0.1m/sec increase in usual gait speed had less hospital days and reduced one-year costs (Purser JL 2005).

This author was skeptical of this program and had concerns about its safety. What I learned from exercising with older Veterans, doing assessments, and adjusting exercise protocols was this:  besides being a lot of fun, the gym is a true respite from illness.  Everybody has chronic conditions, and instead of focusing on them, everyone is working to improve their fitness.  Second, I realized I was biased against exercise because I was fearful someone would get hurt.  Instead, what I have learned is to assess their fitness, then prescribe an appropriate starting place for cardio, weight-resistance training, and balance based on that assessment. Third, older adults need guidance/reminders to do exercises correctly and to adapt exercise to chronic musculoskeletal conditions, and most importantly, to progress the intensity of the exercises.  I also learned it is very hard to predict in whom exercise will really take hold and become life changing.  Prior history of some physical fitness training provides a clue, but is not a guarantee; while many with no background in exercise can just as readily take off.  Exercise is life changing in this cohort.

What do we do about exercise in the significant portion of older adults with varying forms of cognitive impairment?

How do we implement an exercise program that includes cardio, muscle strengthening, and some balance exercise in this population?  What I have learned from Gerofit is that some of the older adults in a program will develop cognitive decline, some will be unrecognized at time of enrollment but become more obvious when they do not learn exercise routines or technique; and in both cases, they will exercise effectively but need supervision and coaching. Those with moderate dementia can fit well into a group exercise program if there is enough staff support or their caregivers are trained and supervised as well.  Folding cognitive impairment participants into a fitness program really provides optimal socialization and engagement when the focus is on fitness and set exercise routines.  

Participants with dementia with past history of physical activity will have motor memory that exceeds cognitive memory.  Regardless, improvement in fitness assessment is the norm if participants engage in the exercise, and there is significant benefit to mood and reduced anxiety.

How can an Aging Life Care Manager™ help?

Aging Life Care Managers have an important role in promoting exercise for their older clients. Care managers can facilitate the interaction of older adults, families, and health care providers, making the initiation of an exercise program more possible.  Care managers can recommend exercise programs for their clients for fall prevention, but can also help to identify clients that have already fallen that could benefit from exercise as an intervention.

The recommendation by the CDC is that if someone has had two or more falls or a fall with injury in the past year, has decreased activities due to changes in their balance, or has demonstrated at-risk screening measures mentioned above, then the following should be done:

• Address chronic medical conditions that may be contributing to changes in balance, including inadequately controlled hypertension.
• Review possible risky medications that may impair balance for indication, efficacy, and safer alternatives.  A careful review of how medications are being administered for adequate adherence, and if a blood thinning medication is appropriate given the falls risk, adherence with meds and risk/benefit of the blood thinner.
• Have a thorough mobility and balance assessment, including drop in blood pressure with standing, vision (acuity and peripheral fields) cognition, and gait assessment.
• Be encouraged to participate in a balance exercise program.
• Address vision, appropriate shoes (no barefoot or socks), lighting and environmental risks.

An Aging Life Care Professional™ is in a unique position to encourage clients and their families to follow through with these recommendations, and begin or continue exercise programs that meet the guidelines.

We, as care managers and health care providers, need to address our own bias about exercise for older adults, in order to become effective advocates for this essential component of health and wellness.

Exercise at any Age, with any Chronic Condition (Part 2)

Steven C. Castle, MD

Republished from: http://www.aginglifecarejournal.org/exercise-at-any-age-with-any-chronic-condition/

Why should Grandma and Grandpa perform muscle strengthening (weight resistance) training?

In the paper “Exercise is the Real Polypill” (Fiuza-Luces C 2013), the evidence of the impact of exercise in comparison with medications on reducing chronic conditions such as  glucose intolerance, lipids, blood pressure, and risk of thrombosis-related cardiovascular events (heart attacks and stroke) is discussed.  The paper reviews a meta-analysis which demonstrates that weight resistance training in particular was equivalent to the polypill (1-3 blood pressure lowering meds, a lipid lowering med, and aspirin), while other types of exercise had a more modest effect on lowering blood pressure in particular. It also identified that there was lower dropout rates in exercise groups (10%) versus the polypill group (20% dropout versus 10% for placebo pill).

In addition, the paper discusses the release of beneficial myokines and anti-inflammatory substances secreted as a result of muscle strengthening exercise, as well as possible substances associated with longevity and reduced risk of colon cancer.  Muscle strengthening exercise provides something different than the more traditional aerobic or cardio-fitness exercises we think of older adults actively engaged in.

What are the components of exercise that help improve balance, reduce falls, and achieve mindful awareness? (Rose D, 2010)

The following are descriptions of the positive outcomes exercise can provide for older adults and how these outcomes can improve balance, reduce falls, and increase safety awareness.

1. Posture and control of Center of Gravity

Older adults who experience a decline in posture often develop inaccurate perceptions of true vertical. Curvature of the spine with decline in flexibility was significantly associated with falls (Kasukawa Y 2010). Mindful awareness of vertical targets (doors, windows, corners) is helpful in restoring postural alignment. Progressive improvement in balance from exercises can start with seated, progress to standing activities, and utilize compliant (foam) or irregular surfaces. In addition, posture control strategies using the ankle, knee, or hip should be included in the exercise training.

2. Strength and Endurance

Muscle strength declines as much as 20-40% between age 30 and 80. Weakness in the body core (alignment of low back, pelvis, hips) contributes to poor balance, and weakness of the muscles in the legs can cause significant challenge in going from a seated to standing position. Strength becomes of increasing importance in individuals with poor balance control. More strength is needed to correct posture to prevent a fall because inappropriate weight shift results in moving the center of gravity off the base of support.

3. Flexibility

Joint range of motion and muscle flexibility decline with age and are associated with impairment in function. Loss of flexibility to perform shoulder or spinal rotation is directly related to functional limitations and increased susceptibility to falls. Reduced flexibility in legs results in less efficient gait (limits endurance) and a decline in balance control (leaning) that also contributes to falls.

4. Gait speed and efficiency

Because of many of the changes described above, stride length and decreased height of each step results in a decline in gait speed. Slow gait results in less stability and shorter steps: shuffling increases the risk of tripping or catching a toe. Exercise programs that require negotiating obstacles and vary surface conditions allow participants to develop a walking pattern that is more efficient, flexible, and adaptive, with more speed to improve stability.

What else can we do to improve mobility and balance?

Falls prevention is difficult to achieve, while mobility and balance awareness should not be.  For the needed behavior changes for exercise and adaption to changes, mobility and balance awareness provides a platform for patients, family, and care managers.  One way to better address mobility and balance awareness is by doing balance assessments, including the 8 foot up and go as part of the Senior Fitness Test, or the more balance-focused Short Form of the Fullerton Advanced Balance Scale (Hernandez D 2008).  These objective measures provide the opportunity to discuss changes in balance which most of us are not cognizant or aware.  Most 80-year-olds will recognize their balance is not like when they were 30, but all 60 and most 70-year-olds are not aware of decline at all; and all older adults are not aware of the size of the risk or that they have the ability to improve their balance through a formal balance exercise program or the need to adjust their lifestyle to match.

Once aware of their change in mobility and balance, the next step is to try and have older adults work with their providers to figure out the cause of mobility and balance changes. A practical approach to identifying the underlying causes is by symptom categories:

• D:  Dizziness/Vestibular:  Benign positional vertigo, vestibular neuronitis, Meniere’s Disease, brainstem infarcts
• LH:  Light headed/Postural Hypotension: drop in blood pressure with standing
• BB:  Bad Balance
• Frame – kyphoscoliosis, leg length discrepancy
• Central – infarcts in basal ganglia, central microvascular infarcts, Parkinson’s, cerebellar
• Peripheral – Peripheral neuropathies, spinal stenosis
• Impaired vision – especially discrepancy between eyes
• Meds – sleep aids, neuropathic pain meds, psychotropics
• Barefoot or socks increases the risk of falls 10-13 times vs. wearing shoes w/heel; poor weight transfer to balls of feet (studies have shown that wearing socks or walking barefoot inside increases the risk of falling 10-14 fold.)
• W:  Weakness – MS, focal weakness (stroke, motor neuropathy)
• PA:  Poor awareness – all of us as we age, dementia (Lewy Body & Vascular in particular)

Visit www.DrBalance.com for more information.

Exercise at any Age, with any Chronic Condition (Part 1)

Steven C. Castle, MD

Republished from: http://www.aginglifecarejournal.org/exercise-at-any-age-with-any-chronic-condition/

Introduction

Exercise and physical activity for older adults was an important theme discussed at the 2015 White House Conference on Aging.  Specific initiatives discussed included the NIH Go4Life campaign and the YMCA initiative to provide intergenerational physical activity.  The implementation of exercise and fall prevention programs on state and national levels sheds light on the importance of physical activity as being viewed as the core to healthy aging and preventing and lessening the impact of chronic disease.  Exercise is now known as an essential component of falls prevention, demonstrated by the fact that $5 million of President Obama’s budget is targeted for the National Falls Prevention Resource Center. Moreover, the CDC has also recognized its importance by providing free online webinars on falls prevention, which are currently being used by health care providers like Kaiser Permanente.  The reduced health care costs as a result of physical activity as well as the reduction of the most common form of accidental injury (falls) may also reduce the need for long-term services prematurely.

Everyone has heard that exercise is good for you, right?  Of us older adults, how many are heeding that advice?  How many of our primary care providers have spent the time to find out and help us do more exercise to the degree that they prescribe or monitor lipid lowering meds and follow cholesterol levels?  One reason why we as a society are falling short, as described below, is because there is a bias AGAINST exercise in older adults that no one is talking about.

Why Exercise?

Exercise is essential to improving balance and reducing risk of falls.  While the National Council on Aging (NCOA) has made a list of evidence-based programs, the evidence is not equal, and there may be other programs in the community which are actually more robust in improving balance.  A recent review on efficacy of exercise programs in preventing falls identified that 32 multicomponent exercises demonstrated reduction in falls by an average of 30%, while three single component (either walking or strength training) programs were not effective (Gillespie LD 2012).  The multicomponent programs target activities that address balance, strength, endurance, and walking.  Among successful programs, total weekly exercise time ranged from 80 minutes to more than seven hours. The duration of programs ranged from eight weeks to two years, while one review suggested a minimal dose of 50 hours of balance exercise is needed to be effective. Participation was improved by having a convenient location, incorporating social activities, and reimbursement for travel costs (Ganz DA personal communication).

In addition, engaging in physical activity is essential for maintaining mobility as we age. Dr. Debra Rose, Director of the Center for Successful Aging at Cal State Fullerton, defines mobility as “the ability to move oneself independently and safely from one place to another.”  The ability to walk 400 meters has been defined as an excellent proxy for community ambulation, which is central to aging in place and quality of life. This became the primary outcome measure of the LIFE (Lifestyle Interventions and Independence for Elders) Study (Pahor J, 2014).  This study randomized 818 (mean age 78.7 years) to physical activity (2x/week in a center and 3-4x/week at home) with 817 (mean age 79.1 years) to a health coaching group.  Of the physical activity group, 85.3% remained independent in community mobility versus only 80.2% of the health coaching group, for a 28% reduction in the risk of becoming dependent (p=.006).

How well are we doing?

Data from the National Health Interview Survey and the Centers for Disease Control (CDC) from interviews of the civilian and non-civilian population show that 42.4% of adults age 65-74 are reporting achieving aerobic activity goals as are 28.1% of adults age 75 and over (goal >50%).  Not bad.

However, only 14.4% of adults age 65-74 and only 7.9% of adults age 75 and over are achieving the goal of both the aerobic and muscle-strengthening activities.  Why aren’t older adults doing more muscle strengthening exercise? Probably because we are not aware of the benefits and have a bias that it will do harm. This is also due to the lack of resources, training, and coaching / supervision needed.

How much exercise should older adults participate in?

The US Office of Disease Prevention and Health Promotion established physical activity guidelines for “Healthy People 2020” to gain substantial public health benefits:

• Avoid inactivity, some physical activity will provide some health benefits (goal <33%)
• For substantial health benefits, older adults should do aerobic activity.
• At least 150 minutes (2 hours and 30 minutes) a week of moderate intensity (goal >50%)
• Or 75 minutes (1 hour and 15 minutes) of vigorous intensity (goal > 33%)
• Or an equivalent combination, performed in 10 minute increments
• Extensive health benefits occur when increased to 300 minutes (5 hours) of moderate intensity or 150 minutes of vigorous activity.
• Muscle strengthening exercises should be done 2 or more days per week of 8-10 exercises that train all major muscle groups (goal >25%)

Additional Recommendations for older adults from the American College of Sports Medicine:

• Maintain or increase flexibility (stretching) for at least 10 minutes a day, twice a week
• To reduce the risk of injury from falls, perform exercises that maintain or improve balance

In the paper “Exercise is the Real Polypill” (Fiuza-Luces C 2013), the evidence of the impact of exercise in comparison with medications on reducing chronic conditions such as  glucose intolerance, lipids, blood pressure, and risk of thrombosis-related cardiovascular events (heart attacks and stroke) is discussed.  The paper reviews a meta-analysis which demonstrates that weight resistance training in particular was equivalent to the polypill (1-3 blood pressure lowering meds, a lipid lowering med, and aspirin), while other types of exercise had a more modest effect on lowering blood pressure in particular. It also identified that there was lower dropout rates in exercise groups (10%) versus the polypill group (20% dropout versus 10% for placebo pill).

In addition, the paper discusses the release of beneficial myokines and anti-inflammatory substances secreted as a result of muscle strengthening exercise, as well as possible substances associated with longevity and reduced risk of colon cancer.  Muscle strengthening exercise provides something different than the more traditional aerobic or cardio-fitness exercises we think of older adults actively engaged in.

A 1-Hour Walk, 3 Times a Week, Has Benefits for Dementia

By GRETCHEN REYNOLDS MAY 24, 2017

Exercise may bolster the brain function and thinking skills of people with dementia, according to a new report. The study’s findings suggest that walking a few times per week might alter the trajectory of the disease and improve the physical well-being of people who develop a common form of age-related memory loss that otherwise has few treatments.

The study looked at vascular cognitive impairment, the second most frequent form of dementia worldwide, after the better-known Alzheimer’s disease. The condition arises when someone’s blood vessels become damaged and blood no longer flows well to the brain. It is often associated with high blood pressure and heart disease.

One of the particular hallmarks of vascular dementia in its early stages, researchers have found, is that it tends to make the brain function less efficiently. In past brain-scan studies, people with a diagnosis of vascular cognitive impairment generally showed more neural activity in parts of their brains that are involved with memory, decision-making and attention than did people without the disease, indicating that their brains had to work harder during normal thinking than healthier brains did.

But while a great deal of research attention has been devoted to Alzheimer’s disease, less has been known about the progression of and potential curbs on vascular dementia. Some research has indicated that reducing blood pressure lessens the symptoms of the disease.

Exercise can likewise improve blood pressure and cardiovascular health. And some research suggests that frequent, brisk walks may improve memory and physical abilities in those in the early stages of Alzheimer’s disease. But, rather surprisingly, few past studies had examined whether exercise might also improve brain function in people with vascular dementia.

So for the new study, which was published in April in The British Journal of Sports Medicine, researchers at the University of British Columbia in Canada and other institutions decided to look into the effects of walking on this type of dementia.

They began by recruiting 38 older people in British Columbia who had been given diagnoses of a mild, early form of vascular cognitive impairment. None currently exercised. All agreed to visit the university’s lab frequently for six months.

On the participants’ first lab visit, the scientists measured their general health and also memory and thinking skills.

They then scanned each volunteer’s brain while he or she concentrated on a computerized test of attention and decision-making skills that involved rapidly clicking keys to indicate the direction that an arrow should point. This scan was designed to reveal neural activity and how hard different parts of the brain were working during the task.

Finally, the scientists randomly assigned their volunteers to start either walking or, as a control group, to visit the lab for weekly education sessions about nutrition and healthy living.

The walking program was simple, consisting of supervised one-hour sessions at the lab three times a week. The walkers were asked to move briskly enough during workouts to raise their heart rates to about 65 percent of their maximum capacity.

“We wanted to have some intensity” in the exercise, says Teresa Liu-Ambrose, the director of the Aging, Mobility and Cognitive Neuroscience Lab at the University of British Columbia and the lead author. Most of the walkers completed all of the sessions and “seemed to be enjoying the exercise” by the end of the six months, she says.

At that point, the volunteers in both groups repeated the physical and cognitive tests from six months earlier, as well as the brain scan. The results showed that the two groups had drifted apart, in terms of the functions of their bodies and brains. Most obviously, the walkers generally had lower blood pressures now than the volunteers in the control group.

But more striking, their brains also were working differently. The walkers’ brains showed less activation in portions of the brain required for attention and rapid decision-making than did the brains of those in the control group.

The differences were subtle, Dr. Liu-Ambrose says, but they correlated neatly with improvements on the cognitive tests. The less someone’s brain had to work to maintain attention and make quick decisions, the better that person typically performed on the tests of general thinking ability.

In essence, the walkers had more efficient brains and better thinking skills now than the control group did, she says.

Of course, this study was short term, lasting only six months, after which the volunteers were free to stop exercising — and most did. Dr. Liu-Ambrose and her colleagues hope in the future to study whether and how rapidly the brains and bodies of exercisers lose any gains if they become sedentary again. They also want to look into different “doses” of exercise and whether shorter or easier workouts would have an effect on brain function in people with vascular dementia.

Obviously, anyone with memory or other cognitive problems should consult with a doctor before starting to exercise and should probably not exercise alone, Dr. Liu-Ambrose says.

But even with so many questions remaining, the results of this study are encouraging, she says. They show that in the early states of vascular dementia, “something as simple and accessible as walking may make a meaningful difference” in how well the brain works.

Reprinted from: https://www.nytimes.com/2017/05/24/well/move/a-1-hour-walk-3-times-a-week-has-benefits-for-dementia.html?_r=1