26 results
11 - Drug research and new product developments for dementia
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
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- 26 April 2019, pp 75-84
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Summary
Drugs marketed for dementia
Drugs that are intended for treatment of the symptoms of dementia must be taken for months or years, as this cruel disease progressively robs the patient of their independence. Like all drugs for chronic disease, there will be a desired benefit to slow the pace of deterioration. But there will be risks and probably side effects upon the body from drugs aimed to intercept the early symptoms of dementia. Those risks are deemed to be acceptable for individual patients within the scope of medical practice, as individual brains respond differently. Science, law and public policy all recognize the reality of having to perform research on living human brains to develop the next generation of beneficial drugs.
Lawyers are familiar with cases of asserted harm from drugs that did not work as the patient's family had anticipated. In classic drug product liability cases, there will be controversies about how much of the deterioration of this patient was or was not attributable to this drug's adverse side effects. “But for the use of drug A, the brain would not have degenerated at the rate that it has done.” But the causation elements of the tort cases against new medicines are murky, when the progression of dementia symptoms are subtle, and where there is a long time between filing the complaint and achieving a jury verdict. The law of strict liability in tort excludes prescription drugs from claims of “strict” liability without need for a showing of the manufacturer's fault. In the actual experiment, clinical research team requires a written consent, usually with a legal disclaimer of liability, as a precondition to delivering that new experimental drug to that patient. That consent to treatment or experimental use may be a sufficient barrier to having a plaintiff 's lawyer take on the liability lawsuit.
Of course, the legal system for injury claims accepts that it will have many delays. Death of the dementia patient may occur while one awaits a full trial, a jury verdict and an appeal. Meanwhile, that delay is running in parallel to the long slow progression of brain deterioration, and ultimately death, which follows an accurate diagnosis of dementia. Most of these liability cases related to drug research are expected to be dismissed or settled.
Contents
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
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- 26 April 2019, pp v-vi
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10 - Dementia and employment issues
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
- Print publication:
- 26 April 2019, pp 69-74
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Summary
Overview of employment issues
Dementia occurring late in life is not likely to involve any employment issue for the patient, because a company employing a worker in his or her eighties is likely to be the rare exception. But early onset dementia at ages 45–65 is possible, and it could pose significant worker performance issues, with discipline consequences, and pose questions about access to remedies for persons claiming dementia disability status.
Dementia is an unusual disability to be claimed in the context of a workplace, because popular culture associates dementia with old age. Visual judgment of the active worker may be deceiving; the physical appearance of the employee is unchanged in early stages, but the brain is degenerating in varying degrees in varying aspects of cognition and memory. How astute and careful the “previously normal” worker had been will determine how their changes in performance may be noticed, and how these changes may then be invoked against them at the time of termination.
Dementia affects employees’ performance of cognitive tasks, and performance deficits affect the likelihood of termination of the employee. The Equal Employment Opportunity Commission (EEOC) guidance documents can be used by employers for specific behavioral cases, to terminate employees for severe breaches of generally applicable workplace discipline standards.
Most cases of disputes over dementia-related employment actions do not appear in the appellate reports. Cases do not get that far. In a 2007 case, a prison supervisor sent a prison employee to see the state psychologist to determine whether incidents of insubordination and confusion were “willful or whether there was another underlying reason for her behavior and performance.” She was not assigned to another job because no appropriate position was said to be available. The news report of the case then noted: “Carver's lawsuit apparently accepts the state's diagnosis of dementia. It seeks damages for economic loss, mental anguish and emotional distress and legal fees.” These cases of workplace dementia-related conflicts are so few that one may expect to receive news media coverage when they reach the public's awareness.
Index
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
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- 11 July 2019
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- 26 April 2019, pp 133-135
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9 - Dementia in probate and guardianship
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
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- 11 July 2019
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- 26 April 2019, pp 57-68
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Summary
Practical relations issues for counselors
The law counselor's skill set for dealing with issues of client dementia does not come prepackaged from a law school class or from conventional solo trial practice. Interactive listening skills are essential. Trusting and compassionate manners are vitally important to the attorney's ability to succeed, with difficult interpersonal situations like the intrafamily dementia response struggles that were described in Chapter 2. This requires strength, character and patience. One must evolve positive behavior responses as the situation evolves.
A very experienced elder law specialist has said it best: “The immediate problem facing the attorney is how to assess the limits of a client's capacity and how to communicate effectively with a possibly impaired client. An attorney must be allowed to take practical steps in an effort to solve these concerns.” This has been dubbed “Slow Lawyering” to serve the client who is exhibiting symptoms of dementia.
A team effort is essential to success. Dementia is a tragic loss of personhood by a loved person, and the attorney should work with experienced social workers and nurses to evaluate the best options for the person and those who love her or him. The prudent attorney should not attempt to operate the response to dementia issues as a solo lawyer, and instead she or he will need to draw support from a team of skilled colleagues.
Knowing what questions to ask, and to whom, at the early stage meetings, is a vital skill. A lawyer in the first meeting with the client's family should ask at the outset about the medical or psychological issues with which the client appears to be struggling. What have the medical assessment reports said? How did the patient/client respond to the bad news of their diagnosis? Local chapters of the relevant patient support associations, especially the Alzheimer's Association, may be a starting point for locating a core group of experienced colleagues.
Veteran estate attorneys will advise the younger lawyer as she or he goes through the process for the first time: lower your expectations.
3 - Tort liability related to dementia
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
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- 26 April 2019, pp 11-22
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Summary
Injuries related to the elderly and persons with dementia
The preceding chapter explains the diagnostic issues for dementia evaluation. This chapter addresses both tortious conduct by persons with dementia who are sued as defendants, as well as injuries suffered by persons with dementia when those harms are caused by other persons.
Accidental injuries appear to increase with advanced age, from a variety of physiological causes. CDC data suggests that age and dementia are not causally related but are co-related. Starting at age 65, the risk of developing dementia doubles every 5 years. By age 85 years and older, between 25 percent and 50 percent of people will exhibit signs of Alzheimer's disease. Up to 5.3 million Americans currently have Alzheimer's disease. According to a national survey, dementia affected 37.4 percent of those aged 90 or older. By 2050, CDC expects the number to more than double due to the aging of the population.
The dominant form of dementia, Alzheimer's disease, is the sixth leading cause of death in the United States, and is the fifth leading cause among persons aged 65 and over. Death or serious injury that is related to accidental causes will be the focus of potential tort litigation.
The problems foreseen by attorneys in accepting the tort case of an injured dementia patient include the conventional proofs of cause, event and harm, but also the status of the patient as of the time of the event: did she or he bear legal responsibility for the tortious act, in some way, that a “normal” person would not? The decision to accept representation for a tort liability claim on a contingent fee also must consider the financial losses which the potential plaintiff has suffered, in the instance where the dementia patient missed no work, had no incapacitation from earnings, may be unable to cogently testify and where (in some cases) medical bills had been paid by the state Medicaid agency rather than by the injured person. In the following sections, we describe the typical tort claims which may intersect with the needs of the dementia patient.
5 - Medicare, Medicaid, disability and other government benefits
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
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- 11 July 2019
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- 26 April 2019, pp 27-36
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Summary
The federal perspective
Dementia and especially Alzheimer's disease have a huge adverse effect on quality of life of the patients and their caregivers, especially families. The counting of all the persons affected would total in the millions of old, young and working-age Americans. Dementia is a worsening public health problem, and both states and the federal agencies have been involved in measures to respond.
Federal funding for research inevitably has a political side to the allocation of funds among competing applicants for the money. Breast cancer, heart disease and other visible campaigns are more likely to draw the attention of the media and the members of the appropriations committee of the House and Senate, inducing an allocation of taxpayer funds for the most “popular disease” causes. So research dollars from the annual budgets of the National Institutes of Health have tended to be spent upon more “hot-button diseases” with much more active constituency and advocacy groups, like breast cancer. The slow manifestation of problems inside the brain is a challenge in many respects; studies of the brain degeneration that is the hallmark of dementia are quite costly. Research funds for dementia have not matched up with all of the needs and opportunities for further exploration of genetics and neurological treatment modalities among the medical research community.
Federal involvement in the fight against Alzheimer's disease was formalized in early 2011, with the enactment of the National Alzheimer's Project Act (NAPA). Pursuant to this legislation, the US Department of Health and Human Services (HHS) published the first National Plan to Address Alzheimer's Disease (AD) in mid-2012. There is slow progress, but there is still a great need for additional funding from voluntary, academic and nonprofit entities to augment the slice of federal funds. Dementia as a political “cause” or “brand” to be “promoted” to the public and to the political audience among key legislators still trails behind cancer and many other disease research efforts.
The role of Medicare Part A on responses to dementia
The 1965 implementation of a tax and health benefits system for the elderly, “Medicare” was a historic breakthrough.
8 - Dementia and financial issues
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
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- 26 April 2019, pp 49-56
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Summary
Overview
Counseling the dementia patient and his or her family is a laudable skill, when done by a counselor who is full of gentle empathy, and who always seeks the safest and most comfortable environment for the patient in her or his later stages of the dementia. But there is no denying that access to high-quality care resources for the dementia patient today will depend upon the private patient's or family's access to money.
A 2016 report found the median costs of nursing home single rooms was $92,738, in a survey of 15,000 long-term care providers. That number would surprise the average middle class reader. Would your family have sufficient funds to keep you, their dementia patient, safe within a well-managed nursing facility for three or four years as your brain deteriorates? It is a frightening prospect that Medicaid residential care sites for the poorest residents with the least attractive services will be the fate of that previously comfortable parent, whose lifetime savings are drained. A 2015 study found “[a] verage total cost per decedent with dementia ($287,038) was significantly higher than that of those who dies of heart disease ($175,136), cancer ($173,383) or other causes ($197,286).”
Dementia does not immediately kill within days or weeks after diagnosis; it is a term to describe a series of symptoms showing progressive deterioration of brain capacity. The family's ability to nurture and protect the dementia patient will be impacted by the set of assets that will be available for the patient's care. “Fewer assets, less comfortable care” is the economic reality.
Access to money truly matters in the dementia story. The fee-for-service medical system, combined with the financially driven investment perspective underlying construction of new residential capacity for elders, makes for a family “scramble,” with members of the family shocked that they must now consider whether the savings available for this patient will match the money demanded by the caregiving system.
Lack of money or inability to manage the patient's assets capably has a consequence: the patient is at the mercy of those family members at home, or of residential care sites which will accept reimbursement at the fixed (and often quite low) state financial assistance payments in programs like Medicaid.
2 - The family dynamics of dementia
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
- Print publication:
- 26 April 2019, pp 5-10
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Summary
Care consultations
We begin with a realistic scenario for the counselor: You have been called for help after a family has experienced the grave difficulty of confronting dementia in a parent, sibling or relative. This chapter discusses the family context within which our later chapters on detailed legal solutions will be presented by the attorney.
Diagnosis of dementia in a loved one brings slow heartbreak, and experience with that sad event carries this message to family members: “Don't try dealing with this alone!” Yes, counselors say, life is unfair, but you must “get over it,” and assume the helper role that your loved one needs for you to perform. Each dementia patient will need multiple caregivers, allies and respite care providers for those caregivers. This requires a family's close attention to their newly discovered responsibilities. “It takes a village” for a family to come out of the dementia experience with a positive unity among the family members.
Though each case is different, the patterns can be recognized and responded to by experienced nurses and social workers. The diagnosing physician is likely to hand over the dementia patient's continuing oversight of care to the nurse or the psychiatric social worker. Dementia specialist social workers start with gathering information for the Care Consultation. This event is a “summit meeting” of those who care enough to be supporting the patient in the face of the dementia diagnosis.
Because the dementia patient can be expected to live several years with the brain degeneration process under way that can lead to death, social workers help that family to understand the stages and the process that they are entering. “Build a Foundation for the Future” is their theme in dealing with the family.
Social workers will meet with the patient's family to set up short-term and long-term goals. What is needed for this patient now? What is likely to be needed in her or his future care? How much will it cost? How will we allocate the care roles and the funding needed?
1 - Introduction
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
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- 26 April 2019, pp 1-4
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Summary
Looking inside the brain
The brain is a wonderfully complex system. Its secrets are hidden until death, when an autopsy can help to retrospectively explain some of the unusual behaviors which had been loosely grouped together by doctors with a diagnosis of “dementia.” Dementia is a broad term for brain disease, a term that includes multiple stages of severity within a chronic disease of cognitive impairment. Alzheimer's is one of the best-known subcategories, among the several forms of dementia, but the subcategories have surprising characteristics and variations.
The key problem that counselors face with diagnosing the medical and psychological problem of an individual has been expressed as “you don't know what you don't know” regarding a patient's brain and its deterioration over time. Until the autopsy is done, we cannot accurately answer all the questions about how dementia has been actually impacting on the brain of this patient. Those counselors and attorneys who want certainty in every case, or a clear winner every time, should not accept roles in which dementia is a factor for that individual or, more frequently, a factor against the defendant driver, midnight shoplifter or agitated homeless person wandering in a city park.
How big the issues are, and will be
Counselors who wish to succeed with claims need to understand the large and growing wave of dementia illness, which is emerging from demographic trends and especially from older aging Americans, a product of relatively healthier living among younger and middle-aged persons.
Yes, there will be a market, especially for legal services. There are estimates of between 3.8 million and 5.3 million adults with dementia in the United States today, projected to grow to approximately 12 million to 15 million by 2050 as “baby boomers” move through the system. Their caregivers, family members and heirs total in the millions as well.
Three of the relevant systems to be addressed in this text, the US legal system, the for-profit and voluntary long-term care system, and the caregiver/medical personnel system, are not well equipped to deal with the imminent and massive volume increase among the post–World War II youth who are today's elder patients. Advising this market is a challenge, but it needs to be satisfactorily completed.
12 - Dementia and criminal justice
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
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- 26 April 2019, pp 85-100
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Summary
Overview
This chapter addresses dementia in the context of criminal behavior by, or directed toward, the person with dementia. It is likely that the individual would be said to be “looking normal,” because it is not easily detected or immediately discernable that an individual person's mental condition was the product of the degenerative brain conditions which are collectively known as dementia.
Unlike an inability to walk or an inability to see objects, dementia in a patient is not perceptible by the average person under normal circumstances. The brain's degenerative condition which makes the person less able to control their actions may lead to a confirmed diagnosis of frontotemporal dementia after neuropsychological tests and/or expensive and complex brain scans are performed. Many studies have been offered and debated on this issue.
It is possible that a defendant between ages 40 and 70 might claim that her or his conduct was the result of early onset dementia. This can be determined by standard forensic psychological assessment testing. It may be augmented by electronic CT or MRI brain scanning and evaluation of brain plaque conditions. Not all dementia claims are valid, of course. “Other problems that may be mistakenly labeled dementia include delirium, psychosis, depression, and the side effects of various medications.”
But it would be rare for a criminal defendant to have solid, persuasive factual brain imaging diagnostic data that would survive critical cross-examination. A claim of mental disease or defect may be attempted, but to the extent that the claims reflect alcoholism, drug use or other transitory impairment of consciousness about behavior, the dementia claim is unlikely to be successful.
The defense case against a criminal charge requires expert witnesses who would testify about their examination of the defendant. Then they would testify that for a patient with frontotemporal dementia, the brain is losing “filters” of sound, prudent judgment. So the loss of inhibitions and scrambled reasoning is a problem that may involve the uninhibited patient in criminal incidents, as actor or victim. The patient is missing the normal social inhibition against doing an action that would be adverse, and their brain is not presently aware that it is wrong to do that action.
6 - Dementia and residential care facilities
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
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- 26 April 2019, pp 37-44
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Summary
Overview
This chapter addresses care of the dementia patient outside of the home, in a residential facility. Those persons with advanced forms of dementia are likely to have “functional and cognitive vulnerabilities” which induce the family to send them into residential care, such as a skilled nursing facility.
For our purposes, this chapter's discussion will include most of what are euphemistically called “senior living options”:
• skilled nursing facilities;
• “continuing care” facilities with multiple subunits for multiple stages of dementia;
• end-of-life hospices;
• remedial rehabilitation facilities;
• assisted living residences; and
• intermediate care facilities.
Older “board and care homes” are rare, yet still exist in some communities.
The common theme is that the resident with dementia had formerly lived in their own home before the onset of dementia, and they are being moved at the impetus of family or friends into a safer and more secure environment, where they will not be permitted to wander away and are less likely to be exposed to risks.
We contrast these living spaces called “assisted living” communities with normal market-price apartments and with homes that are owned or leased by families or individuals, some of whom may be dementia patients; and patients residing in those sites can be served by visiting nurse organizations or go unserved.
We are neither discussing group homes for mentally challenged adults nor addressing state or federal government poverty-related “homes” or residential shelters for veterans, elderly seamen, Native Americans and so on.
This siting for the patient is an important subject for discussion. It is very likely that a residential setting will be part of the patient's future accommodations, during the several years after his or her receipt of a dementia diagnosis. A brief hospital stay after a fall, for example, may lead to a recommendation for transition to a care facility. Unlike an acute disease or severe accident with a long hospital stay, the patient with a dementia diagnosis is likely to remain mobile and under periodic medical care. On a physical level, he or she may be functioning well at first, before entering a slow decline.
Frontmatter
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
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- Anthem Press
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- 11 July 2019
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- 26 April 2019, pp i-iv
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Dementia and Alzheimer's
- Solving the Practical and Policy Challenges
- James O'Reilly, Rhonna Shatz
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- Published by:
- Anthem Press
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- 11 July 2019
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- 26 April 2019
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The ceasing of a family member's ability to reason, function and respond is a tragedy. With major increases in dementia predicted for the coming decade, a book like 'Dementia and Alzheimer's' is needed ever more to cut through clutter of anecdotes and assumptions. Facing the crisis of widespread patient volumes with dementia, 'Dementia and Alzheimer's' explains governmental and private entities' benefit programs for dementia patients, and how government and insurers do and should respond, while integrating sophisticated medical tactics with vital family cooperative responses to their loved one's mental health crisis. The text explains what works and what approaches work best for responses.
4 - Dementia and private insurance
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
- Print publication:
- 26 April 2019, pp 23-26
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Summary
Overview
The diagnosis of dementia is a very expensive and long-term concern. It could be called a “misfit” within conventional health insurance structures that are more attuned to sudden physical problems, because its duration and consequences differ from the classic statistical modeling of heart or cancer losses, and there is no surgical or pharmaceutical “cure” to be paid for by an insurer. This level of multiple uncertainties complicates consideration of the merits of a long-term insurance funding system. And long-term care cost uncertainties are a multinational problem for many developed nations.
Paying for health insurance coverage is essential for many families, but today's need for acute health and tomorrow's need for covering the chronic costs of dementia are not treated the same by insurance purchasers. The cost of paying for long-term care insurance is important; but often the need is less well recognized, until it is too late for an applicant to be accepted by insurers. The prudence of purchasing long-term care insurance will probably appear to be a bargain, in retrospect, for those families which have experienced dementia care costs.
In recent years, some but not all of the costs of dementia care have been borne by Medicaid, the governmental health insurance program which is covered in Chapter 5 of this text. Neither program offers a perfect response for families who suddenly learn of the dementia diagnosis of their loved one, and they often erroneously expect that health insurance would pay the large bill for services.
Group health insurance has been a great benefit for American workers and for retirees in many employment and post-employment situations. The 1976 ERISA law provides a comprehensive federal oversight of the fairness of retirement health plan administration. And the converse is true— that when conflicts about coverage and policy interpretation arise, the preemption power of ERISA shields the large insurance plans from being challenged in state courts for unfairness in design of benefits and bad administrative decisions. If the employer offered a plan for long-term care coverage, then the federal standards would shield that plan from most state-court challenges.
Appendix: Finding medical reference sources about dementia
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
- Print publication:
- 26 April 2019, pp 129-132
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Summary
Note: Refer to Chapters 13 and 14 for textual citations.
1. Bressler, S. L. and Menon, V. Large-scale brain networks in cognition: Emerging methods and principles. Trends in Cognitive Sciences 2010;14:277–90.
2. Zalesky, A., Fornito, A., Harding, I. H. et al. Whole-brain anatomical networks: Does the choice of nodes matter? NeuroImage 2010;50:970–83.
3. Mesulam, M. M. From sensation to cognition. Brain: A Journal of Neurology 1998;121 (Pt 6):1013–52.
4. Catani, M. and ffytche, D. H. The rises and falls of disconnection syndromes. Brain: A Journal of Neurology 2005;128:2224–39.
5. Damoiseaux, J. S., Rombouts, S. A., Barkhof, F. et al. Consistent resting-state networks across healthy subjects. Proceedings of the National Academy of Sciences of the United States of America 2006;103:13848–53.
6. Chen, S., Ross, T. J., Zhan, W. et al. Group independent component analysis reveals consistent resting-state networks across multiple sessions. Brain Research 2008;1239:141–51.
7. Goldman, R. I., Stern, J. M., Engel, J., Jr. and Cohen, M. S. Simultaneous EEG and fMRI of the alpha rhythm. Neuroreport 2002;13:2487–92.
8. Tavor, I., Parker Jones, O., Mars, R. B., Smith, S. M., Behrens, T. E. and Jbabdi, S. Task-free MRI predicts individual differencees in brain activity during task performance. Science 2016;352:216–20.
9. Finn, E. S. Nature Neuroscience 2015;18:1664–71.
10. Fornito, A., Zalesky, A. and Breakspear, M. The connectomics of brain disorders. Nature Reviews Neuroscience 2015;Mar;16(3):159–72. doi: 10.1038/nrn3901.
11. Sporns, O. The human connectome: Origins and challenges. NeuroImage 2013;80:53–61.
12. Buckner, R. L., Krienen, F. M., Castellanos, A., Diaz, J. C. and Yeo, B. T. The organization of the human cerebellum estimated by intrinsic functional connectivity. Journal of Neurophysiology 2011;106:2322–45.
13. Yeo, B. T., Krienen, F. M., Sepulcre, J. et al. The organization of the human cerebral cortex estimated by intrinsic functional connectivity. Journal of Neurophysiology 2011;106:1125–65.
14. Choi, E. Y., Yeo, B. T. and Buckner, R. L. The organization of the human striatum estimated by intrinsic functional connectivity. Journal of Neurophysiology 2012;108:2242–63.
15. Friston, K. J. Functional and effective connectivity: A review. Brain Connectivity 2011;1:13–36.
7 - Adult protective services in dementia cases
- James O'Reilly, Rhonna Shatz
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- Book:
- Dementia and Alzheimer's
- Published by:
- Anthem Press
- Published online:
- 11 July 2019
- Print publication:
- 26 April 2019, pp 45-48
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Summary
Protection for dementia patients
Dementia is an isolating condition, one in which the socially active adult gradually experiences a confused fear or withdrawal from active participation in business, family events or other community activities. Sometimes that person needs protection, and our society offers a structure to deliver that protection in the form of “adult protective services.”
Because the person may no longer have a large circle of supportive family and friends, the general community using tax funds provides a “safety net” for the more isolated dementia patients, in the form of state-funded social worker intervention. Adult protective services (APS) steps in to assure that the local probate court will be able to shield the adult from a loss of his or her physical safety. But its intervening role ends when a guardian is appointed by the court and takes over the supervision of the adult patient's care. State legislation gives special powers to the APS workers.
Police who encounter an adult with apparent dementia are the persons most likely to call for APS intervention. The APS mission is to actively respond to the needs of those adults who are otherwise mentally incapable of caring for themselves.
The role of APS is intended to be parallel to the comparable public agency “child protective services” function. Often, the same set of social workers can be housed in the same structure like a unit within the local social services department. APS training is intended to cover the legal action which the workers may take for protection of a dementia patient.
The usefulness of a safety net intervention to protect against harm is decided by the local probate court, the court which has a vital role in appointing guardians, as prescribed in state laws. Most conventional law practice settings do not lead the attorney to interact with APS, and it is likely that a select number of probate specialists in each community have regular interactions with the APS team. Tax funding of the service is a relatively modest corner of local tax expenditures. Federal shared funding for APS is managed through grants from the Administration for Community Living.
What REACH can teach us about TSCA: Retrospectives of America's Failed Toxics Statute
- James T. O'Reilly
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- Journal:
- European Journal of Risk Regulation / Volume 1 / Issue 1 / March 2010
- Published online by Cambridge University Press:
- 20 January 2017, pp. 40-50
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Comparative risk assessments in the chemical safety field sometimes adopt a lofty view of the purposes of legislation. This personal essay is not lofty, and it is not just another professor's comparison of the purposes of the European Union's REACH with American regulatory programmes. I write today as an individual, as the last active remaining participant of the small group of industry players in 1975–76 who helped to negotiate the details of the 1976 US Toxic Substances Control Act (“TSCA”). As advocates for industry we won the key arguments over the law's terms and conditions, but the decades since have not shown TSCA to be a triumph for anyone.
Food swamps and food deserts in Baltimore City, MD, USA: associations with dietary behaviours among urban adolescent girls
- Erin R Hager, Alexandra Cockerham, Nicole O’Reilly, Donna Harrington, James Harding, Kristen M Hurley, Maureen M Black
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- Journal:
- Public Health Nutrition / Volume 20 / Issue 14 / October 2017
- Published online by Cambridge University Press:
- 22 September 2016, pp. 2598-2607
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Objective
To determine whether living in a food swamp (≥4 corner stores within 0·40 km (0·25 miles) of home) or a food desert (generally, no supermarket or access to healthy foods) is associated with consumption of snacks/desserts or fruits/vegetables, and if neighbourhood-level socio-economic status (SES) confounds relationships.
DesignCross-sectional. Assessments included diet (Youth/Adolescent FFQ, skewed dietary variables normalized) and measured height/weight (BMI-for-age percentiles/Z-scores calculated). A geographic information system geocoded home addresses and mapped food deserts/food swamps. Associations examined using multiple linear regression (MLR) models adjusting for age and BMI-for-age Z-score.
SettingBaltimore City, MD, USA.
SubjectsEarly adolescent girls (6th/7th grade, n 634; mean age 12·1 years; 90·7 % African American; 52·4 % overweight/obese), recruited from twenty-two urban, low-income schools.
ResultsGirls’ consumption of fruit, vegetables and snacks/desserts: 1·2, 1·7 and 3·4 servings/d, respectively. Girls’ food environment: 10·4 % food desert only, 19·1 % food swamp only, 16·1 % both food desert/swamp and 54·4 % neither food desert/swamp. Average median neighbourhood-level household income: $US 35 298. In MLR models, girls living in both food deserts/swamps consumed additional servings of snacks/desserts v. girls living in neither (β=0·13, P=0·029; 3·8 v. 3·2 servings/d). Specifically, girls living in food swamps consumed more snacks/desserts than girls who did not (β=0·16, P=0·003; 3·7 v. 3·1 servings/d), with no confounding effect of neighbourhood-level SES. No associations were identified with food deserts or consumption of fruits/vegetables.
ConclusionsEarly adolescent girls living in food swamps consumed more snacks/desserts than girls not living in food swamps. Dietary interventions should consider the built environment/food access when addressing adolescent dietary behaviours.
Measuring the difference between actual and reported food intakes in the context of energy balance under laboratory conditions
- R. James Stubbs, Leona M. O'Reilly, Stephen Whybrow, Zoë Fuller, Alexandra M. Johnstone, M. Barbara E. Livingstone, Patrick Ritz, Graham W. Horgan
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- Journal:
- British Journal of Nutrition / Volume 111 / Issue 11 / 14 June 2014
- Published online by Cambridge University Press:
- 17 March 2014, pp. 2032-2043
- Print publication:
- 14 June 2014
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To date, no study has directly and simultaneously measured the discrepancy between what people actually eat and what they report eating under observation in the context of energy balance (EB). The present study aimed to objectively measure the ‘extent’ and ‘nature’ of misreporting of dietary intakes under conditions in which EB and feeding behaviour were continuously monitored. For this purpose, a total of fifty-nine adults were recruited for 12 d, involving two 3 d overt phases and two 3 d covert phases of food intake measurement in a randomised cross-over design. Subjects had ad libitum access to a variety of familiar foods. Food intake was covertly measured using a feeding behaviour suite to establish actual energy and nutrient intakes. During the overt phases, subjects were instructed to self-report food intake using widely accepted methods. Misreporting comprised two separate and synchronous phenomena. Subjects decreased energy intake (EI) when asked to record their food intake (observation effect). The effect was significant in women ( − 8 %, P< 0·001) but not in men ( − 3 %, P< 0·277). The reported EI was 5 to 21 % lower (reporting effect) than the actual intake, depending on the reporting method used. Semi-quantitative techniques gave larger discrepancies. These discrepancies were identical in men and women and non-macronutrient specific. The ‘observation’ and ‘reporting’ effects combined to constitute total misreporting, which ranged from 10 to 25 %, depending on the intake measurement assessed. When studied in a laboratory environment and EB was closely monitored, subjects under-reported their food intake and decreased the actual intake when they were aware that their intake was being monitored.