Should we stop using the word “elder” or “elderly”?

According to the Telegraph in the UK, the answer is “yes.” And it seems that more and more, clinicians in the aging business are dropping the use of the word “elder” and “elderly” and instead are using the term “older adult” (as do I).

Interestingly, there seems to be a lot of resistance in the legal field for dropping this term – in fact, an entire legal field uses the dread term, e.g., “elder law attorneys.”

What do you think? Is the term “elder” OK? Or is it tantamount to calling someone a “codger” and the like? I’m curious what you think.

Treating and Preventing Alzheimers

What can we do to treat Alzheimers disease? I watched again a great talk by Dr. Frank Longo MD/PhD at Stanford, a rock star if there ever was one in the Alzheimers research and treatment field. It’s a great little talk and I recommend watching it if you’re a practitioner, researcher, or even just an interested caregiver or patient – there’s a lot here.

We all know about the medications available – there are the FDA approved medication treatments basically in two groups: the so-called cholinesterase inhibitors, such as Donepezil (Aricept), Galantamine (Reminyl, Razadyne), and Rivastigmine (Exelon). And then there are the “NMDA receptor antagonists,” of which there is one medication currently approved and on the market, Memantine (e.g., Namenda).

Basically all of these medications can help, but they are only treatments. Generally a patient who is helped but Aricept or Namenda can expect maybe 6 months where the progression of their dementia (as Alzheimers is a disease of progressive cognitive decline) is effectively halted. In rare cases some improvement in cognitive functioning can occur. However, these drugs all treat the symptom of the disease (e.g., the cognitive dysfunction) and they do not treat the underlying issue – the underlying brain damage that causes the cognitive deficits in the first place. Also, these drugs (like all drugs) have side effects.

So, drug therapies are interesting and as a psychologist who has worked almost exclusively in inpatient medical settings for the past several years, I like to keep abreast of what’s happening in the world of the somatic therapies. There are a lot of research treatments out there as well that we can talk about… I may go into that in a later post. Needless to say, a lot of research is currently going on in the Alzheimers disease treatment front as far as medical treatments go.

However, as a psychologist what I’m personally most interested in are health-related behaviors, like diet, exercise, coping behaviors, et cetera. Are there things that people could be doing to prevent Alzheimers disease or even treat it after it’s taken hold?

The answer is, yes. I was greatly impressed when I heard Dr. Longo speak at last year’s Updates on Dementia in Foster City (which I try to attend every year… pamphlet on the 2013 conference is here if you want to attend). He basically gave the same lecture that I linked to above (although at the conference he included a lot more information about current research on drug therapies and diagnostic techniques). In both lectures, he spoke at length about the nexus of research that relates to the subject of health behaviors and how they relate to Alzheimers disease and prevention. He focused on three areas – diet, exercise, and so-called brain games or brain training activities.

First, there’s the so-called “Mediterranean diet.” This relates to the idea that a diet rich in monounsaturated fats (such as olive oil), low in saturated fats, and high in lean proteins like fish (and low in red meat, which I don’t like to hear), and plenty of vegetables and fruit, somehow imparts a protective effect on people when it comes to development of progressive dementia. There does seem to a significant body of research that indicates that adherence to such a diet can reduce the risk of several forms of dementia, including Alzheimers disease – eating fish two to three times a week probably helps reduce risk of Alzheimers disease, and this probably relates to the positive effects of the Omega-3 fatty acids (which you can also get from flaxseed or chia seeds as well). It may or may not help people who currently suffer from Alzheimers.

Then, there’s exercise and maintaining a proper body weight. One of the things that impressed me is that Dr. Longo cited several studies, both with humans and animal (rat) models that people with excessively high Body Mass Index (BMI) tended to develop higher levels of amyloid plaques than those of normal BMI (which maybe has something to do with the fact that beta-amyloid serves a function in the body of metabolizing cholesterol, and is also related to oxidative stress). So, maintaining a normal BMI may be a critical way to prevent (or treat) Alzheimers disease.

Regarding exercise: Frank Longo cited several studies, including the 2012 EXCEL study (which focused on weight training) and the 2011 study of Erickson et al., both of which demonstrated nothing short of “striking” effects. In the EXCEL study, subjects essentially reversed the effects of their Mild Cognitive Impairment syndrome (often a precursor to full-blown dementia) by engaging in weight training twice per week for six months, and in Erickson et al., subjects engaged in some brisk walking several times per week – and on average subjects increased their hippocampal volumes (the hippocampus being a brain structure crucial to learning and memory) by on average, two percent. In neither case were these exercise programs particularly taxing.

So, both cardiovascular exercise and progressive resistance training appear to impart significant benefits. Engaging in a regular exercise program may not only prevent the onset of Alzheimers disease, but may actually be a treatment as powerful as some of our current FDA approved therapies (!!!). Think about this as a treatment – what if you went to a doctor and they told you they could offer you a treatment that could potentially reverse the shrinkage of your hippocampus, reverse your cognitive impairment issues, and the side effects are all positive, e.g., reversing of your diabetes, healthy weight loss, increased muscle tone, decreased depression, better sleep…. Would you take that treatment? I would!!!

Finally, there’s the question of brain exercises. I’m sure you’ve seen the ads for computer software such as from the companies Posit Science and Luminosity. The idea here is based on some reasonable logic – the idea is when it comes to Alzheimers disease, “use it or lose it” is the watchword. Also, people who have a lifetime history of being intellectually engaged seem to run a reduced risk of developing frank cognitive impairment (based on the well-known observation that higher levels of educational attainment seem to impart a protective effect against Alzheimers disease).

So, here’s the idea: if instead of spending one’s retirement watching reruns of “Gilligan’s Island,” one instead plays these games, or does crossword puzzles… does that prevent or treat Alzheimers or MCI? Unfortunately, Dr. Longo, as well as I, have to give you the bad news. Amongst the three areas outlined here (diet, exercise, and ‘brain exercises’), the literature on this seems to be the poorest. While I would certainly tell you that it’s better to remain intellectually engaged and challenged in late life, and it probably helps, at best the positive effects of playing these “brain games” or making a point of doing the New York Times crossword puzzles on a daily basis, is likely vanishingly small. If active engagement in life truly is an Alzheimers disease preventative – it’s not to be found in brain games, it’s to be found in having a purpose in life, a hobby, social activities, stuff like that.

But do we need research to tell us that? Think about what the boosters of these software packages are telling us – that somehow it’s a good thing for an older adult to sit in front of their computer for even more time in their average day (which an average Baby Boomer does probably enough of anyways) and play computer games as a way to forestall the onset of dementia, INSTEAD of getting out of the house and going to the gym, or just going on a walk?

This is me on my soapbox here – I think the reason why these companies are making so much money based on such a flimsy premise is that it appeals to people in the same way drug therapies do. “Here,” they say, “treating or preventing your Alzheimers disease or dementia is as easy and effortless as taking a pill or playing some computer games (and doesn’t require the hard work and effort involved in making healthy dietary choices or getting a regular exercise program)!” The problem is, pills have side effects, these software programs likely don’t do much, and exercise is essentially free – and it works. So, save the potentially hundreds of dollars you might spend on expensive brain training software and maybe hit Costco and lay up a few filets of salmon, and then use the rest to buy that gym membership you were thinking about (or, maybe just save your money and instead go out and walk!!!!).

(BTW, just wanted to say – before you start any exercise program, it’s probably smart to check with your physician first. Never hurts.)

The Crumbing State of Long Term Care Funding in the United States

This may be a bit of a downer, so be warned. However, I plan on following this post with a more uplifting, upbeat analysis of the state of home care alternatives to LTC placement (stay tuned!) – so just keep that in mind.

In the news recently was a conference of some high-level policy experts from the SCAN (Senior Care Action Network) foundation – which is a think-talk spinoff of the SCAN Health Plan, which is a modest-sized health plan with a number of beneficiaries mostly in southern California and Arizona.

At the conference these experts basically groused about something we all kind of know at this point – in the United States our ability to save for our own retirement is of course poor, but it’s downright terrible when it comes to saving for the cost of long term care. Which is unfortunate, because if you live past the age of 65 there’s apparently around a 70% chance you’ll need to stay at least temporarily in a skilled nursing facility (SNF).

The problem is that nursing home costs have soared over the past decade or so, and are projected to double within the next 15 years if current trends continue. Currently the cost of a nursing home bed in the United States costs between 50,000 and 100,000 annually – which is a cost structure that puts even college tuition and fees to shame (another sector of the economy in crisis due to near-hyperinflation).

At the SCAN conference the policy they noted several distressing issues, which we’ll review here. From the Forbes article linked to above:

“The existing system for funding paid long-term supports and services is built on a wobbly three-legged stool: low private savings, an underfunded Medicaid program, and a hobbled private long-term care insurance market.

 For whatever reason, the long term care insurance market has basically crumbled in this country. This may have something to do with the current financial crisis – insurance companies need to grow their premiums via investments in order to make a profit and also pay off beneficiary claims. In the current financial environment, basically at the same time their investments have tanked (recent stock market rally aside) and interest rates on savings have been basically set at subzero by the Federal Reserve, their costs have gone through the roof. Typically, insurance companies are rather risk-averse when it comes to their investments – they aren’t hedge funds. So, they’ve been investing in bonds. And they’ve been getting hammered.

Regarding “low private savings” – I think that this is somewhat of an unfair point, when you think about it. How in the name if all that is Holy can an family not in the privileged 1% even hope to afford to save up the tens (if not hundreds) of thousands of dollars one might need to pay for the cost of a year or two in a SNF? And mind you, again, if costs double in 15 years, it strikes me that it’s impossible, practically speaking, to put away enough unless one is essentially functionally super-rich.

Finally, they note Medicaid. In California, we have something called Medi-Cal, which is our state’s version of Medicaid. It’s generally the way everyone else pays for their skilled nursing care (everyone aside from the super wealthy, that is, and aside from those that require 30 days or less of skilled nursing, who can tap their Medicare benefits for this).

This is how Medicaid / Medi-Cal it works, from what I understand. First, you have a person (typically an older adult) who needs SNF care. Then they see the cost of private care, which is astronomical – this older adult may have a home, a car, and a savings account, and maybe some retirement money and a pension – but they realize that this money would be very quickly wiped out of they tried to do private pay. So, this older adult may try to do home care for awhile, or see if they can hack it in an Assisted Living Facility (ALF) – a less expensive, but still very expensive option. They may have already tried these things. They visit a financial planner and an attorney to discuss how to qualify for Medi-Cal.

In order to qualify for Medi-Cal, you have to prove that you are indigent and that you deserve to have the government pay your SNF tab. So, in this situation the older adult has to find a way to do what’s called “spending down” – which refers essentially to the process of getting rid of all of your ‘excess resources’ so that you can  meet the legal definition of being indigent. Then, Medi-Cal will pay for your long term care. Note there are a lot of exemptions (e.g., you can keep one car for transportation, one home, et cetera) but if you get any of it wrong the mistake can be financially ruinous (people have been pursued for five and six-figure nursing home bills due to not properly following spend-down rules).

Getting on Medi-Cal / Medicaid can be a lifesaver, however, as SCAN participants noted, the Medicaid program is underfunded and we can assume that it will continue to be so (at least, I will).

In the way of a personal anecdote, a social worker that I work with has let me know of an informal test she did of how nursing homes in California tend to treat “Medi-Cal beds.” She calls up Nursing home X and says, “I have this patient who needs placement at your facility – Medi-Cal is his funding source. Do you have any room?” Nursing home X says no. She calls Nursing home X back a half hour later, disguises her voice, and says, “I have this patient and he can pay privately. Do you have room?” She gets an enthusiastic yes. From what I am aware,  Nursing home X may be breaking the law here (e.g., nursing homes are not allowed to deny a patient admission based on their funding source), but I have a feeling this is a rampant problem. Medi-Cal pays at best an anemic, discounted rate to SNFs, and private pay (and Medicare) are much more generous, so they want to avoid it where possible. In the end, this means that the low-quality nursing homes that tend to be on probation with surveyors, provide poor care, and get frequent complaints are likely the ones with a number of “Medi-Cal beds” whereas the higher quality nursing homes that can attract private pay patients simply have a couple of token Medi-Cal beds just for appearances sake.

I’ve worked in nursing homes in California. We have a two-tiered system of skilled nursing in our state, at best.  And it’s getting worse.

What the SCAN participants suggested was a variety of reforms which focused on funding mechanisms almost exclusively. They suggested that people shouldn’t be inflexibly forced to spend down in order to qualify for Medi-Cal (which in many, but not all cases involves essentially sheltering assets so they don’t have to go towards paying for the exorbitant costs of nursing care). Unfortunately, that may have the downside of confounding what the actual point of Medicaid / Medi-Cal, which is reserving the program for the indigent.

Also brought up amongst the SCAN conferees, apparently, was the idea of “universal long term care,” basically a mandatory long term care insurance plan for all Americans. While this idea probably has some currency in the current political ethos, this was one of the areas that conferees didn’t agree on – probably because it’s not clear that it would do anything to address the problem of upward-spiraling costs in long term care.

Otherwise I wasn’t impressed with their proposed fixes, at least how they were represented in the Forbes article – it was all quite status quo. Other than discussions of nips and tucks in how to address affordability (none of which I think will work, politically or logistically), there was no discussion of implementing wide ranging innovation or reform in the business of skilled nursing care, or ways of encouraging competition as a way to bring down costs.

Regarding the issue of political will to start trying to address the sorry state of long term care in this country, my wife recently sent me this link. You ever heard of the “Class Act”? Well, you won’t – because it’s dead. This was a half-hearted attempt on the part of the Obama administration (and opposed by the Republicans) to implement a national, voluntary long-term-care insurance plan as part of the Affordable Care Act (ACA, also known as Obamacare). To be fair – it was hard to support it. The premiums were projected to be far too large to be affordable, and the program was generally thought to be unsustainable otherwise, so it was scrapped as part of the “fiscal cliff deal” from a few months back (As an aside, as far as the ACA goes – it’s a pretty good deal for older adults overall; apparently the way some of the law is structured, it essentially provides a subsidy for older workers over younger ones. While that’s great – at this point the ACA does nothing to address the downward spiral in the long term care market).

My take is that for the long term care industry to survive and be relevant in the future for the majority of Americans (as opposed to being just a niche specialty care market for the 1% and an inhumane warehousing system for the indigent), the LTC industry and the regulatory and funding structures surrounding  it need to innovate and evolve.

Let’s be clear – innovation is happening in long term care – but from where I’m standing it seems to be happening most intensively in home care. So, in a future article (or articles), I’d like to discuss and feature some innovative businesses that are capitalizing on the fact that more and more older adults are staying in the home rather than going into skilled nursing care (which doesn’t mean that demand for SNF care is going down, unfortunately – it just means there’s more older adults out there), and showcase them as examples. I personally believe that even with the coming ‘demographic tsunami’ we can innovate a long term care infrastructure that can serve the needs of this country’s growing older adult population – but we’re going to need to innovate, and fast – and we’re going to have to start fostering an environment where that innovation can happen.

Dementia Syndrome of Depression, AKA “Pseudodementia”

Let’s talk about older adults and depression. According to the NIMH, the overall prevalence rate of depression in older adults overall (age 65+) is around one percent, which is considerably lower than estimates for their younger counterparts. That’s the good news. The bad news is that once you add the presence of physical ailments that might lead one to require hospitalization or home healthcare, prevalence rates rise to approximately 11 and 13 percent, respectively.

Depression is not a normal part of aging, and actually, is even more abnormal in older adults than in their younger adult counterparts! Also, memory loss is not a normal part of aging, either. There’s a connection between these two issues.

An interesting thing about major depression is that it expresses itself a bit differently in older adults than their younger counterparts. Before we get into that, let’s review the diagnostic criteria for clinical depression according to the DSM-IV (soon to be outmoded by the DSM-V, coming to academic bookstores near you).

As is the case with psychiatric disorders, you need to be diagnosed by having the requisite number of symptoms from all of the appropriate categories – a little from column A, a little from column B, etc. To be considered a major depressive episode, you need to be suffering from five or more of the following symptoms over a previous two-week period, AND two of the symptoms have to be either 1) depressed mood or 2) lack of pleasure:

1)    depressed mood (“most of the day, nearly every day”)

2)    lack of pleasure (AKA anhedonia)

3)    weight loss or weight gain

4)    insomnia or hypersomnia (sleeping too much or sleeping too little)

5)    psychomotor agitation or retardation (speeding up or slowing down)

6)    fatigue / lack of energy

7)    feelings of worthlessness or guilt, low self-esteem

8)    cognitive symptoms (memory problems, concentration problems)

9)    Suicidal thoughts

Note a couple of things about the above. We can kind of group the symptoms into two groups – there’s so-called “neurovegetative symptoms,” or basically symptoms that relate to basic systems of the body, chiefly relating to the autonomic nervous system. These include changes in weight, changes in sleep, energy levels, and cognitive symptoms. Then there are the more “existential” symptoms of depression remaining.

Older adults suffering from depression tend to express it more readily with neurovegetative symptoms, as opposed to the more dramatic, existential symptoms of depression like suicidal thoughts, depression, or guilt feelings, which may not even be present at all in older adults. Oddly enough, one can actually suffer from depression and not even know one is depressed – a not-unimagineable scenario where one suffers from so-called “depression without sadness,” – not an uncommon picture of depression in older adults.

Let’s talk about what’s commonly referred to as so-called pseudodementia (what I prefer to call dementia syndrome of depression – more on that later). The idea behind this is that a sufferer, typically an older adult, has a major depressive episode and due to how depression tends to manifest itself in older adults, they get diagnosed with dementia. An unsophisticated primary care physician seeing an older adult complaining of withdrawal from activities, poor sleep, weight loss, and increasing forgetfulness (all the while denying depressed mood) might miss what’s actually going on here.

The interesting thing about so-called pseudodementia is that it’s not actually “pseudo” at all – I suppose the thinking here is that since the cause of the memory problems in the case of pseudodementia is not “organic” in nature (although the NIMH confidently disagrees with this, stating “Depressive illnesses are disorders of the brain”), it’s really “depression masquerading as dementia.”

But of course this isn’t really accurate, depending on how you think about it –  the term “dementia” simply refers to the phenomenon of a sufferer who has significant deficits in cognitive functioning (e.g., such as memory plus one other important domain of functioning, such as language or attention), leading to significant deficits in social or occupational functioning. It’s a term that’s agnostic about causes – dementia can be caused by Alzheimer’s disease, strokes, medications, metabolic illnesses, and a whole host of other causes. It’s an umbrella term. Dementia can be stable, progressively declining, irreversible, and sometimes (as is the case with depression) – reversible. Therefore the term I believe is more accurate than pseudodementia, again, is dementia syndrome of depression, or DSD.

Of course, things become more complicated when you drill down into the phenomenon of late-life depression. Not only does it express itself differently, the presence of a depressive episode in an older adult also tends to be associated with an elevated risk of being later diagnosed with dementia. And, dementia tends to be associated with depression (particularly in the early stages). Still, this entire phenomenon is why it’s critical for any practitioner – if you’re working with an older adult and you suspect DSD, you need to aggressively treat this person for depression before you can definitively diagnose other causes of dementia (e.g., such as dementia secondary to Alzheimers Disease). In many cases, if the depression is successfully treated in a person suffering from dementia secondary to depression – the DSD lifts and the older adult is restored to baseline functioning.