Today the University of Massachusetts Boston has made the fourth edition of “The Guide for Elders: Planning that Protects You and Your Assets” available for free online. The Guide which started in 1993 and has continued to be revised over time (most recently in 2010) hopes to be a resource for older adults so they know what steps to take to get and keep their affairs in order. There are “increasing numbers of reports of elderly people being abused, exploited, or victimized in ways that rob them of their life savings and their dignity. Those cases involving financial exploitation saw elders victimized by friends, neighbors, and even family members.”

Financial and health care matters are often confusing and the Guide provides their readers with clear descriptions and scenarios to illustrate problem areas. After reading the Guide you should be able to answer a number of questions: Why do I need a power of attorney, health care proxy, or will? When should I consider entering a nursing home? What can I do if I get “ripped off,” or if I am the victim of a crime or abuse?

Although not intended as a substitute for individual counsel and assistance, the Guide will allow you to prepare and determine if your situation needs additional professional advice. As clearly stated in the introduction, “Elders need to know what steps they can take to avoid being victimized and what they should do when and if it happens to them. This Guide’s…emphasis is on prevention and avoidance of problems, with the recognition of the old adage that an ounce of prevention is worth a pound of cure.”

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The winter edition of the American Society on Aging’s publication “Generations” focuses on medications and older adults. The writers and guest editor did a great job of synthesizing information on medications and their usage for a non-clinician. I was most struck, however, with the overarching message that we actually know very little about medications’ true effects on elders. A particular article highlighting this point was titled “Medicating Elders in the Evidence-Free Zone” by John P. Sloan.

In Sloan’s work he asks us to take a step back from the escalating debate around the growing health care and drug costs in America, and to consider the drugs themselves. “The newest shift in prescribing,” he writes, “is the shift from drugs that treat conditions to drugs that prevent them – particularly in elders.” Drugs are being prescribed for older adults to treat chronic illnesses and help them feel and function better, but many drugs are also taken with the goal to prevent illness and prolong life. Sloan provides an example: A 90-year-old woman is told she has low bone density and is prescribed a drug to help. Before leaving the office, she asks her doctor how long it will take for the medicine to have a beneficial effect. The doctor tells her it will take 2 to 3 years before they’ll see any noticeable improvement. Knowing her life expectancy to be not much longer than 3 years, she wonders about the benefits of preventative medicine for someone her age.

This example raises number of questions for the reader:  Do the frailest, oldest-old want to prolong their life and prevent future illness? If so, at what cost and with what negative side-effects? Are we confident preventative medicines will help this population?

Sloan addresses the last question in his article and I was startled by the answer. Older, frail adults are members of what has been called an “Evidence-Free Zone.”  Drug trials, which are the only support for prescribing preventative medications, do not include older adults, frail individuals, people with more than one chronic illness, or people taking multiple medications. Consider this for a moment. Drug trails, so they are safe for participants and accurately testing a drug’s effects, cannot include complicated people. Older adults, however, are the most heterogeneous and complicated group when it comes to their medical care and conditions.

The author states point blank, “When an older person takes a medication, no one has any idea what is going to happen.” This is because of the four “Absurdities of Prevention in Frailty”:

  1. You can’t predict the outcomes of a drug in people whose biology is unpredictable.
  2. Clinical trials never include frail elders because frailty by definition includes multiple pathologies.
  3. Older people are less likely to benefit from preventative medicines.
  4. Preventative medicines, even if safe in everyone else, are just riskier in frail elders.

Drug trials also do not test for outcomes that may matter most to older people like functional status, cognition, mood, quality of life, and caregiver burden. Geriatric patients, who use our medical system most, may be surprised to find little is known about them and their health. I know I was. The good news is geriatricians and medical researchers are aware of the problem. They continue to investigate the best ways to help older adults age well and provide helpful information for the rest of us so we can stay informed about caring for ourselves and our loved ones as they age.

This post by Robert Powell from MarketWatch (The Wall Street Journal) discusses a bleak outlook for America’s state of retirement security. In my opinion, the most important thing mentioned in this article is how the lack of financial education among workers can directly affect their retirement wealth. Many people hold misguided expectations about their retirement portfolios and believe they have more in Social Security benefits, employer pension plans, or health and long-term care coverage than they really do (Helman, VanDerhei, & Copeland, 2007). What’s worse, this misinformation can actually drive planning behavior so much that ill-informed workers, rather than doing nothing, are losing significant portions of their pension wealth because they take inappropriate and detrimental action (Chan & Stevens, 2003). Not everyone has expendable income to play with, yet the financially-informed worker is 5 times more likely to respond to pension incentives accordingly and increase their pension wealth (Ekerdt & Hackney, 2002).

The article highlights many other topics that are important to educate yourself about. We need to fix Social Security, we need to contribute more to our own 401(k)s and retirement savings, we need to make sure more workers are covered by pension plans, and so forth. Yet, many of the suggestions for fixing these issues are based on what’s feasible for the typical, middle class worker.

Should you really force people to put part of their wages into an IRA when they need every penny of every paycheck to cover the costs of food, shelter, and clothing? If yes, can you tell them what percentage of their income they must contribute? Are you then required to financially educated them or give them free access to financial experts? Will they even live long enough to reap the benefits of their automatic IRA account?

Longevity may be increasing in this country but we should always be cautious of statistics. Longevity varies widely by gender, race, income level, health status, region of the country…I don’t know, pick something. In fact, life expectancy has actually declined for women between 1997 and 2007 which is extremely rare in developed countries. “The nation has experienced a widening gap between the most and least healthy places to live. In some regions of the country, men and women are dying younger on average than their counterparts in nations such as Syria, Panama and Vietnam.”

As with any policy change or “universal” action, all parties who will be affected by the changes must be considered. I encourage you to read Powell’s article and to approach his solutions cautiously. Though it cannot be the only answer, there is one that seems to me most helpful and realistic: Financial education for all.

 

One of my older posts told you how to find your lost pensions if you live in the New England area. Today I received an email from the Pension Action Center’s Director, Ellen Bruce, and I’d like to share their success story with you. If you considered contacting them in the past perhaps this will encourage to give them a call. The New England Pension Assistance Project reached a milestone: they’ve recovered a total of $40 million in pension income! Below please find Ellen’s email with more information.

 

Dear Friend, 

This month, the New England Pension Assistance Project, part of the Pension Action Center at the University of Massachusetts Boston, celebrates a significant milestone: $40 million in recovered pension income since opening its doors in 1994. Hundreds of retirees in New England have more money to live on today as a result of the Center’s work.

“Pensions enable individuals to remain financially secure in retirement, helping them stay out of poverty,” said Ellen Bruce, director of the Center. “Unfortunately, complex pension laws and corporate red tape sometimes make it difficult for people actually to receive the pensions they have earned. The New England Pension Assistance Project is here to ensure that workers and retirees receive what they have earned.” 

Assistance from the New England Pension Assistance Project is available free of charge to current residents of any of the New England states, and to people whose pension plans or former employers are based in one of these states: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and Connecticut. The Project handles a variety of issues relating to retirement income benefits, including eligibility and vesting, problems with 401(k) or other retirement savings plans, survivor benefits, and problems in finding pensions that have become lost due to corporate changes and bankruptcies.

Funded by the U.S. Administration on Aging, the New England Pension Assistance Project is part of AoA’s Pension Counseling and Information Program that currently serves 29 states.  The Project is operated by the Pension Action Center at the Gerontology Institute of the McCormack Graduate School of Policy and Global Studies at the University of Massachusetts Boston.  For more information, visit http://www.pensionaction.org or call (617)287-7307 or (888)425-6067.

Thank you for your continued support,

Ellen Bruce Signature

Ellen A. Bruce, J.D. 

Director

In the field of gerontology, long-term care planning is a very hot topic. I can’t pick up an aging newspaper or journal without some mention of this issue. That is not to say I am surprised by the attention it gets. One of the most startling facts I learned in class was that unpaid caregivers provide services valued at $450 billion per year!

Long-term care (LTC) is an essential expense and while many dream of a healthy retirement filled with vacations and relaxation, this is far from the reality. Most people will grow old and frail and need LTC during their retirement years. Unfortunately, most are not planning for it and the government is cutting back on affordable options that could help. Though Americans are not planning for LTC, they are worried. A California poll on this issue found that two-thirds of people don’t know how they will be able to afford LTC. They are just as concerned about this expense as the cost of their future healthcare. So if people are aware of the problem, why the inaction? Perhaps it’s because they don’t know where to begin. What affordable options do they have so they can age with dignity and independence, living how they want in the place they choose?

Information to Consider:

What is Long-Term Care = when you are not able to complete personal care or other daily activities on your own. This is most often the result of a chronic illness or disability. In some cases, the illness or disability may include cognitive impairment.

How Much Care Do You Need = about two-thirds of today’s elders will need LTC support. Women need care longer (on average 3.7 years) than men (on average 2.2 years), mostly because women typically live longer.

Who Will Provide Support = help comes from 3 sources: (1) family and friends (2) agencies with certified staff or (3) hiring help on your own. For many, a blended approach to LTC is needed.

How Do You Plan and Pay = the National Care Planning Council has a detailed guide to planning for your LTC needs. This 7 step plan involves understanding the care settings and available government programs, who you should call on for help, how you can pay for services, and how you can protect your assets. More information about the public and private sources for funding LTC can be found on the Department of Health and Human Services website.

Getting Started:

It may be daunting to see all the steps and options to consider. I’m asking you to start thinking about this decades before it’s needed! Perhaps having the following conversations is a better starting point for some of us. Begin thinking about LTC and your own life. Then when you do your research, you’ll be aware of your personal needs and desires.

(1) Talk with your spouse, adult children, friends, or siblings about whether they might care for you if I became ill or disabled. Tell them how you feel about relying on their help.
(2) Ask your family doctor whether you might be at higher risk for needing long-term care someday based on your medical and family history or lifestyle risk factors.
(3) Talk with a financial planner, insurance agent, attorney, or other financial advisor about how you would pay for long-term care services if you need them.

The Fall 2011 Generations issue is all about rituals. The journal’s content was on my mind as I gathered with family and friends this Thanksgiving. I began thinking beyond the fun and food, and looked more toward the larger meaning of holiday events. What are our cultural and family traditions, and how did my grandparents benefit from developing these rituals?

The significance of our family traditions mattered not only to my grandmother, but to the rest of us as well. She started our “Thanksgiving Brunch” years ago when her children began splitting time between their spouse’s families and their own during the holidays. It was important for her that the whole family get together during the holidays and without the stress of having to be in two places at once. Many of the rituals we perform during Thanksgiving (the time we eat, the food we serve, the location where we gather, the family photo) started with my grandmother and added meaning to the holidays.

But what meaning did our Thanksgiving rituals hold for her? Cooking the Thanksgiving brunch for our family could be seen simply as habit. Yet consider how this made my grandmother feel: making the meal reminded her of the personal, familial, and cultural roles she’s held over the years.  As I think back on it now, she had a specific Thanksgiving ritual. The same food was prepared year after year. Only when the food was ready did she greet everyone (don’t bug her while she’s cooking!). She’d watch her family interact and get their share of the meal before she took any food for herself. When she finally sat down at the table, the eating could begin. Even in later years when she was no longer the cook (and assumed the role of supervisor), her ritual was still performed every Thanksgiving.

Older adults often perceive rituals as a way to build successful families and strengthen relationships. Researchers show that the most positive aspects of holiday rituals are maintaining family contact, togetherness and sharing, making memories, and communication. My grandmother knew that even when she passed away we would keep these holiday rituals alive and continue to see each other for brunch every year. In times of change or struggle, rituals become extremely important because of the continuity, order, and predictability they provide to families. In the final years of my grandmother’s life, keeping to the holiday traditions provided structure for us and for her as we began accepting the inevitable. Our holiday activities over the years left an emotional imprint on everyone involved, allowing each family member to recall positive memories from these events.

For older adults and those of us who study them, rituals provide insight into the lives they hope to live, the types of social and cultural settings they find meaningful, and the experiences they wish to share and turn into their legacy. So when family gets angry because you forgot to bring the cranberry sauce this year, consider why breaking this tradition would make them so upset. Rituals, particularly for those in later life, connect people to something bigger through shared experiences and the meaning that they create. “It’s not Thanksgiving without cranberry sauce!”

The 2011 OWL Mother’s Day report  starts with a very strong statement: “Health care for all is a women’s issue…” Why would this be? Men also need and use our health system. Yet, the case is made for how women’s lives are affected by health care coverage or a lack there of. Women play a large role in managing care for sick family members, most often providing this care themselves. Widows can often be left impoverished if their husbands’ chronic illnesses dwindled savings accounts and assets. In late life, women find themselves 60% more likely to need help with basic daily activities (i.e. eating, dressing, bathing) compared to men. This paints a picture in our minds: Grandma spent her 60’s and 70’s caring for grandpa. He had heart problems and diabetes but she made sure he took his medications, got to his appointments, and was cared for till the end. Now in her 80’s, grandma finds herself sick, poor and alone in a big, empty house. Since women’s life expectancy continues to exceed that of men’s, this story is all too familiar.

“After a lifetime of caring for others, older women often need affordable care but find that the costs are high and their options are severely limited.” I’ve described to you a common late-life situation for women. Let’s keep this image in our minds as we discuss how the Affordable Care Act (ACA) aims to support Americans as they age. People, like grandma, find themselves skipping preventative services because Medicare requires them to pay a 20% co-payment. This cost is found to be a disincentive for approximately half of Medicare beneficiaries who do not use preventative services available to them.  Grandma lives on a fixed income of $1,000/month from Social Security (the average benefit is $1,177) and this means that paying a $30 co-pay to see her doctor gives her $30 less for grocery shopping that month. She isn’t feeling sick, so she prefers to spend the money on food. This begs the question: Should she have to make that choice?

 
The good news is changes to our health care system are happening over the next few years and should support people in old age. Below I’ve highlighted some of the changes but please read the full report or see this great summary of the Health Reform Law from the Kaiser Family Foundation for more details.

Health Insurance Reforms

  • Medicaid will be expanded to cover 16 million Americans (all legal residents up to 133% of the federal poverty level will be eligible)
  • Retroactive cancelling of insurance because of accidents or sickness, denying coverage because of pre-existing conditions, and basing premiums on health status, gender and genetics will all be prohibited
  • Insurance companies must devote at least 80 – 85% of premium dollars received to medical benefits and quality improvement and they must provide justifications for any excessive rate increases, making this information available to consumers

Medicare

  • People who reach the “donut hole” on prescription drug coverage will get a large discount on drugs and biologics and this discount will grow each subsequent year.  The hole will be closed in 2020
  • Beneficiaries will receive a free annual exam, free flu and pneumonia shots, and any covered service that is given a grade A or B by the U.S. Preventive Services Task Force must be provided at no cost
  • Medicare payments will be reduced for hospitals that have high HAC rates (hospital-acquired conditions) and incentives will be provided to hospitals that improve their transitional care and partner with community services to reduce readmission rates

Long-Term Care 

  • The Community Living Assistance Services and Support (CLASS) Act will provide a voluntary long-term care insurance program available to all working Americans. When an individual becomes eligible and needs long-term care services an average cash benefit of $50/day will be given to help them pay. Beneficiaries have control over their own care, so this includes paying family or friends who provide help at home.
  • Home and Community Based Services (HCBS) aim to provide a network of services within state and local areas to meet the needs of elders aging in place. A new protection called under HCBS will attempt to prevent “spousal improverishment” by only counting the ill spouse’s income when determining eligibility.
  • Nursing home care will be improved as the ACA aims to make the system, procedures, staffing and care more transparent and regulated. The Elder Justice Act is a part of this, in an attempt to identify and prevent elder abuse.

In the United States everyday people are providing 85% of needed long-term care for their family members and friends. These roles are generally unpaid and at the expense of their own careers, health, and well-being.  Rather than creating a health system that works, we have created a system that to a large extent depends on informal caregivers yet still costs us 17% of GDP.  The ACA is not a perfect system and will not be fully up and running for a few years. Still, it is a step in the right direction and will expand coverage to 95% of the population and support those who care for the people they love.

If you find yourself bombarded with mixed messages or feeling confused about the new health care changes, I encourage you to at minimum read the OWL Mother’s Day report’s appendix. Here the authors address a number of major myths about the Affordable Care Act and answer some common questions about the policies and coverage.

2010 saw the passing of the Elder Justice Act (EJA), the most comprehensive federal elder abuse law in U.S. history. We know from earlier studies that roughly 11 to15% of people ages 60 and older face some form of elder abuse each year. Experts agree this number is under-reporting and the scope of the problem is larger than we realize. According to a 2008 study by the Metlife Mature Market Institute et al., the perpetrators of elder financial abuse are typically not strangers. They are often businesses, service providers, family and friends who have gained the trust of the older adult. Here are some interesting findings:

  • The victims of elder financial abuse are losing a combined total of $2.9 billion dollars annually.
  • Women are twice as likely to be victims of financial abuse as men. Most of these women are age 80-89, living alone, and requiring some help in the home or with their health care.
  • Nearly 60% of the perpetrator were men, mostly aged 30-59.
  • The amount of money stolen by family or friends increased during the holidays.

Recently the researchers at MetLife updated these numbers, discovering that elder financial abuse cases have risen 12% since 2008. Though instances are increasing, data suggests that only one out of 43.9 financial exploitation cases are reported. Unfortunately the newly passed EJA can do nothing without the support of Congress and the President. Currently the Act only provides Congress with the authority to spend up to $777 million over the next four years on elder abuse. To actually see the money used, however, a separate bill must be passed by Congress and signed by the President.

Until this can get sorted out, and the EJA can strengthen existing adult protective services (APS), here are ways the report says you can watch out for yourself:

  • Stay Alert – Don’t leave valuable items, cash, or checkbooks out in the open. Don’t be left out of decisions about your finances. Don’t sign anything without reading first and having someone you trust review it. If you are a concerned family member, be sure to ask periodically about the elder’s financial situation and keep an eye out for changes in their behavior (i.e. sudden worry about money) and any other sudden financial changes or unusual expenses.
  • Stay Organized – Keep track of possessions, mail, and checking and savings account balances. Know who is calling and use an answering machine or caller ID to screen calls. Know who is asking for personal information and why (never provide this over the phone!)
  • Stay Informed – Know where to go if you suspect abuse (your local APS, the police, or get help from bank employees). Talk to an attorney and keep track of your will, future caregiving arrangements and power of attorney.
  • Report Abuse – Anyone (e.g. elder, family member, physician, bank teller, etc.) suspecting elder abuse should be reporting it to the local APS. Reports can be made confidentially and reporters are protected from civil and criminal liability. It is always better to err on the side of caution.

The Elder Justice Act comes almost 40 years after the passage of the Child Abuse and Neglect Prevention Act. Congress, and the general public, see the value in protecting vulnerable children from abuse and today we spend upward of $7 billion to help this effort. Surely vulnerable older adults deserve the same protection.

This morning I got an email from the Beverly Foundation about a new interactive map that aims to help adult children and seniors locate the elder transportation options in their area. The Beverly Foundation is a non-profit organization who’s mission is to spur new ideas about improving and expanding senior transportation, and to increase options available to elders throughout the country.

One of the ways the Beverly Foundation hopes to promote this mission is through community outreach with its new map. Their STAR search surveys from 2000-2011 award funding to the best and brightest Supplemental Transportation Programs (STP) each year. With responses from about 1,400 STPs they acquired quite a list and now are sharing it with us. To find transportation options in your area check out the map on their website: here.

No one likes to think about the day when they’ll have to stop driving, but the truth is on average men will live for 6 years and women will live for 10 years with the inability to drive. Many will rely on family, friends and neighbors for support but being dependent on others for getting around is unappealing. Some elders say they don’t feel right asking people to take a day off from work. Others have little to no family or friends nearby. STPs offer an alternative and seniors can organize their own transportation so they don’t not feel reliant on others. And often these services are completely free unlike a taxi, bus, or train. Check out the map to find out if there’s one near you.

I’m not a medical doctor but I hear so many older adults say things like “I can’t find my keys, am I getting Alzheimer’s?” or “My sunglasses were right on my head!  I hope I’m not losing it.”  I feel the record needs to be set straight. Cognitive illnesses are a growing concern for older Americans. The increasing number of delirium and dementia cases among elders have advanced the general public’s awareness of these issues. That’s great but don’t let it confuse you into thinking you and everyone around you has a problem (After reading below if you are legitimately concerned you should get the opinion of a medical professional right away).

Forgetfulness comes with age and you may now have a harder time remembering. But when you get tested for dementia they are not exactly checking to see how forgetful you are. Can you draw an analog clock showing it is 2:35? Will you know how much change you’d receive paying for a $1.95 pack of gum with a $5? Can you name 12 different animals? As you can see, these questions have nothing to do with how often you misplace your keys. John Hopkins Medicine tells us that doctors consider both your short and long-term memory loss AND one or more of the following:

  • aphasia – language problems
  • apraxia – organizational problems
  • agnosia – unable to recognize objects or tell their purpose
  • disturbed executive function – personality and inhibition

Dementia is a progressive decline in memory and at least one other cognitive area (attention, orientation, judgment, abstract thinking and personality). Types of dementia all involve structural damage to the brain. Dementia is rare in under 50 years of age and the incidence increases with age; 8% in >65 and 30% in >85 years of age. Alzheimer’s Disease is a type of dementia.

Delirium is an acute disorder of attention, memory and perception and is preventable and treatable.  It is typically of short duration but severe, and is believed to either disrupt brain metabolism or brain chemistry, both of which can significantly affect brain functioning. The diagnosis is unfortunately missed in more than 50% of cases.

Mild Cognitive Impairment (MCI) is a condition involving problems with memory or another mental function (for example language) severe enough to be noticeable but not serious enough to interfere with daily life. This can progress to dementia and the risk of progression to dementia is elevated for people with stroke, depression and a high burden of other medical conditions.

If you want to do more to help, the Alzheimer’s Association’s Walk to End Alzheimer’s is happening in the next few months all around the country. I know I’ll be walking to increase knowledgeable awareness about dementia and delirium and to raise money to help find a cure (or even just a better understanding) of these heart-wrenching diseases.

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