Saturday, August 28, 2010

Diabetes, Insulin Resistance Linked to Alzheimer's from MedPage Today

By Crystal Phend, Senior Staff Writer, MedPage Today

Insulin resistance and type 2 diabetes may contribute to the development of one type of brain plaque linked to Alzheimer's disease, according to an autopsy study.

An analysis of autopsy samples from 135 Japanese men and women found that high insulin and glucose levels appeared to accelerate the formation of neuritic plaques, especially among those carrying a high-risk gene for Alzheimer's, Kensuke Sasaki, MD, PhD, of Kyushu University in Fukuoka City, Japan, and colleagues, reported.

The association of neuritic plaques with higher levels of two-hour post-load plasma glucose, fasting insulin, and insulin resistance measured in the decade before death was found to be independent of other risk factors like age, blood pressure, smoking, and cerebrovascular disease, Sasaki and co-authors wrote in the Aug. 25 issue of Neurology.

Thus, "adequate control of diabetes might contribute to a strategy for the prevention of Alzheimer's disease," they concluded.
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Thursday, August 26, 2010

Dilation Of Blood Vessels Restores Muscle Synthesis In Elderly

University of Texas Medical Branch at Galveston researchers believe they've found a way to use widely available blood pressure drugs to fight the muscular weakness that normally accompanies aging.

The discovery draws on research linking the loss of muscle mass with age-related changes in the behavior of the hair-thin blood vessels, or capillaries, which supply muscles with the amino acids they need for growth.

"When a young person eats food, insulin secretion causes the blood vessels in the muscle to dilate, so a lot of blood goes into the muscle and a lot of amino acids are available to build muscle proteins," said UTMB professor Elena Volpi, senior author of a paper on the work ("Pharmacological vasodilation improves insulin-stimulated muscle protein anabolism but not glucose utilization in older adults") now available in the "Online Ahead of Print" section of the journal Diabetes. "Older people's blood vessels have far less response to insulin, but we found that if you give them a drug that causes them to dilate, you can increase the nutritive flow to the muscles and completely restore normal growth."

Drugs that induce blood vessels to widen, called vasodilators, are commonly used to control high blood pressure and prevent angina. The UTMB study used sodium nitroprusside, a drug used in hospitals and administered intravenously.
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Polio Effects Surfacing Decades Later

Mayo ClinicImage via WikipediaDecades after the last polio epidemic in the United States, people who had long since recovered from the disease are feeling its effects again. The August issue of Mayo Clinic Women's HealthSource provides an overview of post-polio syndrome, its causes and treatment options.

In the first half of the 20th century, polio was one of the most feared diseases in America. Paralytic polio causes pain and weakness in the arms or legs and problems with swallowing and breathing. This occurs when the polio virus attacks and kills motor nerve cells, which control muscles.

Since 1955, when the polio vaccine was introduced, the disease has all but disappeared in the United States. But in the early 1990s, patients who previously had polio and recovered began to report progressive pain and weakness in muscles and joints as well as increasing problems with fatigue.

Mayo Clinic researchers have been following a group of adults in Minnesota who had polio between 1935 and 1955 to learn more about the lingering effects of the disease. Researchers suspect that aging plays a role. "If you've already lost nerve cells in your youth because of polio and the remaining cells have been working twice as hard, you're going to have even more difficulties as you start to lose nerve cells to aging," says Anthony Windebank, M.D., neurologist and director of the Regenerative Neurobiology Program at Mayo Clinic in Rochester.

In addition, people may limp or walk differently because of polio damage and, as a result, be more prone to wear and tear and arthritis in the knees. Finally, people who've learned to compensate for polio-related problems may find that the compensation causes considerable fatigue.

There's no specific treatment for post-polio syndrome itself but most symptoms can be treated or managed. For patients who suspect polio is causing symptoms, the recommendation is to seek an evaluation with a provider who understands the illness and has experience treating neuromuscular disorders.

Source: Mayo Clinic Women's HealthSource
Polio Effects Surfacing Decades Later
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Staying Intimate Later In Life

Many older adults -- ages 65 to 85 -- remain sexually active and consider sexuality an important part of their lives. But with age, sexuality also can be challenging. The August issue of Mayo Clinic Health Letter looks at some of the challenges and solutions to cultivating sexual desire later in life.

For men and women, medical conditions that affect general health and well-being can interfere with sexuality. Diabetes, high blood pressure and high cholesterol can affect the cardiovascular system, and adequate blood circulation figures strongly in arousal during sexual activities. Conditions affecting joint health, such as osteoarthritis and rheumatoid arthritis, may impair movement or cause pain. A decrease in sexual drive (libido) is common in older adults.

For women, changes in body shape that occur naturally can affect feelings of desirability. Decreased estrogen levels result in thinning of vaginal tissues and less natural vaginal lubrication. These changes may reduce sexual desire because of pain or discomfort during sexual stimulation. With age, orgasms typically become more muted.

For men, testosterone levels gradually decrease over time, meaning erections may take longer to achieve and may not be as firm. Erectile dysfunction becomes more common as men age.

But the desire for emotional intimacy defies age; the focus on a physical relationship can shift increasingly to an emotional one. This change tends to bring older adults together for satisfying sexual intimacy even if arousal and orgasm aren't the same as they once were. While the clock can't be turned back, Mayo Clinic Health Letter describes ways to enhance sexual experiences later in life:

Communication: Partners need to talk openly about any physical difficulties as well as changes in sexual function or sexual enjoyment.

Women's options: Nonprescription products can help with vaginal dryness due to menopause. Options include a nonprescription, water-based moisturizer (Replens) or non-glycerin lubricants such as System Jo H20 or Slippery Stuff. Vaginal estrogen, available by prescription, is another option.

Men's options: Drugs such as sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra) are available to treat erectile dysfunction. However, they don't affect libido.

Other medications: Antidepressants, opiate-type drugs used for pain relief, and high blood pressure medications may affect sexual function negatively. A doctor may be able to offer other treatment options.

Exercise: Regular exercise can improve energy levels and also helps stimulate blood flow to the genitals.

Counseling: A trained therapist can offer education, suggestions, and tailored interventions to help address sexual concerns.

Source: Mayo Clinic Health Letter
Staying Intimate Later In Life
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'Village' Movement And Community Health Clinics Offer Alternative Models Of Care

NPR: "The village movement dates to the 2001 founding of Beacon Hill Village in Boston. This year, the Village to Village Network launched to help other communities create their own senior support groups. Other sites created to help arrange help for seniors who want to live independently at home: Senior Helpers' services include companionship, conversation, meal planning and house cleaning as well as Alzheimer's and dementia care." Fifty of these nonprofit organizations already exist nationally, with another 100 in the works. "Only 5 percent of Americans ages 65 and older live in group quarters like nursing homes. In recent years, this share has been steadily declining (based on 2008 American Community Survey data). ... A lot of villages are in better-off neighborhoods, but Capitol Hill and others use private grants or public money so they can offer a steeply discounted annual fee to those who need it" (Ludden, 8/23).
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NPR: Technology Can Help Seniors Stay In Homes

Headquarters of National Public Radio in Washi...Image via WikipediaNPR continued its series on seniors aging at home.

Part two examined a company called Adaptive Home, "one of a growing number of startups that use monitoring technology to revolutionize elder care. These companies are also betting on a big market as the baby boomers enter old age. Chris Bridgers says a basic package includes about a dozen motion sensors placed strategically around a house. They can provide adult children with a stunningly detailed rundown of a parent's day" (Ludden, 8/23).

Part three continued looking at "wired homes," with an example of a older couple in Georgia monitored via live video hookup to a company in Indiana. "The scene may not seem so strange in the era of Skype, when many people use the computer to keep in touch with far-flung relatives. But ['telegiver' Denise] Cady can see almost every move the Fitzgeralds make. Their house is wired with video cameras ... ResCare's services start at $600 a month and can run well over $1,000 depending on how much active monitoring is needed. But that's still a lot less than the average nursing home" (Ludden, 8/24).
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Medical Jargon: A Barrier to Quality Care | Medicare Solutions Blog

Logo of the Centers for Disease Control and Pr...Image via WikipediaBy Lucy Dylan

The Center for Disease Control and other government officials are working to improve communication between doctors and patients. The Health Literacy Action Plan, a new government initiative, hopes to improve patients’ understanding of their health by simplifying medical language. According to the program’s web site, target groups include minorities and lower income individuals, two groups likely to lack basic health literacy.

One step health insurers have taken is to use a program that essentially translates medical jargon to plain English. The program, marketed by Health Literacy Innovations, scans a doctor’s document and suggests simplifications. Meanwhile, many state Medicaid programs have opted to provide health information written for people with fourth to sixth grade reading level, ensuring that people understand the medical treatments they need.
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Lookin' Good In Those Genes | Medicare Solutions Blog

Candles spell out the traditional English birt...Image via WikipediaBy Lucy Dylan

People all over the world are living longer. Worldwide, few people reach the age of 100, and those who do are often celebrated for their longevity. Only one out of every six thousand people will blow out the candles on their 100th birthday cake. Even fewer people (one out of every seven million) have lived beyond age 100 into their 110s or 120s. Currently, the United States and Japan are home to the largest numbers of people aged 100 or older world wide.

But how can you live such a long life?
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Younger Americans Support Social Security, Poll Finds - NYTimes.com

Scanned image of author's US Social Security card.Image via WikipediaBy PAULA SPAN

It’s not surprising that Americans over age 65 are virtually unanimous in seeing Social Security as an important government program. As a group, they rely on it as the single greatest source of income in retirement.

But a poll commissioned by AARP to mark Social Security’s 75th anniversary (President Franklin D. Roosevelt signed the transformational legislation on August 14, 1935) has found something even more interesting: young people line up solidly behind Social Security, too.
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Wednesday, August 25, 2010

The Paying for Eldercare Puzzle

By Alex Guerrero

When thinking about paying for eldercare, it can be overwhelming to consider the many different financial and care options.Differing eligibility requirements and different types of benefits can further the confusion. By grouping options into categories, we can help families better understand programs available to them.

Short Term Resources

Long term elder care often begins by using short term resources. Medicare, Medigap, private health insurance and similar programs for military retirees and veterans such as TRICARE and CHAMPVA all provide limited time benefits for long term care. These programs’ benefits are designed for seniors recovering from surgeries or accidents and are not meant as a long term care solution. However, they will pay a high percentage of the cost of nursing home care for up to 100 days.

Long Term Resources

Resources for ongoing elder care costs can be grouped into 5 categories.

Pensions and Retirement Resources

The first resources most families tap for the cost of eldercare are recurring pensions and retirement savings. These include social security benefits and veteran’s pensions such as the Aid and Attendance benefit and a family’s own savings. The costs and types of long term care have changed dramatically in recent years and unfortunately many of those who require care today did not retire with the recurring monthly income to cover those costs.

Home Equity

With inadequate recurring monthly income to pay for long term care, many families use the equity of their homes as a financial resource. Reverse mortgages and to a lesser extent home equity loans can provide a significant amount of monthly income. There are several new financial programs that allow seniors to tap their home equity as an alternative to reverse mortgages. However, these are only available in some states and their value is somewhat diminished due to the drop in home prices in recent years.

Insurance: Long Term Care and Life

Most families do not have long term care insurance, but those that do receive direct payments to help them with the cost of care. Life insurance is more common and there are multiple options for exchanging a policy for cash. For seniors in poor health, viatical settlements and accelerated death benefits allow them to receive a lump sum payout. Life settlements and death benefits loans are two other options for seniors with life insurance that require care but are not terminally ill.

Programs for the Financially Challenged

There are a variety of programs provided by federal, state and non-profits organizations for the financially needy. Chief among them is Medicaid in its various forms. Qualified seniors can receive Medicaid benefits in various ways; direct care, waivers to receive home care, and family caregivers can even receive payment for the care they provide. Supplemental Security Income can provide a boost to Social Security checks. Some cities offer government housing with assisted living services.

Eldercare Loans

In the last few years, there has emerged a new class of loan specifically targeted at helping families pay for assisted living. The loans have rapid approval processes and are structured to allow multiple family member or friends to share the cost of paying for an elderly individual’s care. These are a good option for families in shorter term, crisis situations.

Reducing the Cost of Care

Another way to think about paying for long term care is to think about how one might reduce the cost of care. This is especially valid for families that care for their loved ones at home. Some respite care programs offered by non-profits and Area Agencies on Aging offer as much as 30 hours / month of care for free or for very reasonable fees. This can offset the need for full-time home care services. There are also federal and state tax credits and deductions for caregivers. The cost of medications can be reduced by purchasing prescriptions online in bulk or from Canadian pharmacies. By combining many of these ideas, families can reduce their cost of care by hundreds or even thousands of dollars per month.

The website, PayingForSeniorCare.com, offers a deeper investigation of the Pros and Cons of each of these financial and care resources. Their Eldercare Financial Resource Locator Tool helps families find which options are relevant to them to help pay for home care, assisted living and long term care. Alex Guerrero serves as the Director of Operations for the organization.

TIME GOES BY | GRAY MATTERS: Social Security's Diamond Jubilee - By Saul Friedman

FDR Signs SSA
”We can never insure one-hundred percent of the population against one-hundred percent of the hazards and vicissitudes of life," said FDR that day. "But we have tried to frame a law which will give some measure of protection to the average citizen and to his family against…poverty-ridden old age.”
I have not yet celebrated the Diamond Jubilee – the 75th anniversary last week of the adoption of Social Security. That’s because I suspect President Obama may consider agreeing to a cut in benefits for future retirees by raising the retirement age, which would be disastrous for them and for his presidency.

So far, he has not said whether he’s for or against the idea, advanced by Republicans and his fiscal commission. Once he was against it but now, as you’ll see, we cannot be sure.

In the days leading up to the August 14 anniversary, Obama said most of the right things. In his White House proclamation, Obama recalled that in the midst of the Great Depression,
“...the Social Security Act brought hope to some of our most vulnerable citizens, giving elderly Americans income security and bringing us closer to President Roosevelt’s vision of a nation free from want or fear.”
He added,
“My administration is committed to strengthening...and protecting Social Security as a reliable income source for seniors, workers who develop disabilities and dependents....Let us ensure we continue to preserve this program’s original purpose in the 21st century.”
He didn’t say how, but presidential proclamations are usually empty of substance. Obama followed with his weekly Saturday radio address in which he repeated his administration’s
“...obligation to keep that promise (of Social Security) for our seniors, people with disabilities and all Americans – today, tomorrow and forever.”
Then he vigorously promised to protect Social Security from
“...some Republican leaders in Congress who are pushing to make privatizing Social Security a key part of their legislative agenda if they win a majority in Congress this fall.”
Privatization, allowing workers to create personal retirement accounts, like 401(k)s, he said, is
“...an ill-conceived idea that would add trillions of dollars to our budget deficit while tying your benefits to the whims of Wall Street traders and the ups and downs of the stock market.”
That’s true enough, but to mix a metaphor, Obama was beating a dead straw man.

George W. Bush’s failed attempt to sell privatization in 2005, crippled his presidency. And as the Associated Press pointed out in reporting on the president’s speech,
“...most Republicans, in fact, are wary of touching that idea because Social Security is virtually sacrosanct to voters, particularly seniors.”
Indeed, the most prominent Republican favoring privatization of Social Security and Medicare, Representative Paul Ryan of Wisconsin, has gotten little support from his Republican colleagues.

What was missing from Obama’s address was a single proposal to solve Social Security’s long-term shortfall which the program’s trustees estimate will come in 2037. That is when the program’s $2.6 trillion trust fund, which is held in treasury bonds, may run out. According to the trustees, a one percent raise each in the payroll taxes split between employee and employer enacted now would end the problem. Even now, the trust fund is continuing to grow with interest payments of more than $100 billion a year.

During his presidential campaign, Obama criticized Republican John McCain for favoring cuts in benefits. And Obama, who repeatedly has said that Social Security was not facing a “crisis,” offered a sensible, relatively painless proposal, which is now favored by most Social Security advocates.

Obama proposed raising the amount of one’s income that is subject to the payroll tax from the present $106,800 to $250,000. And in a gesture to the middle class, he proposed exempting from the tax the first $20,000 of a worker’s salary. (Some advocates would abolish the ceiling, which would go a long way towards putting Social Security in the black for the rest of this century.)

But Obama has not repeated that proposal nor has he said what he would oppose. Instead, he has created a commission to cut the deficit, a commission which is populated with right-wingers who are hostile to Social Security and believe, wrongly, that Social Security adds to the deficit.

Even before the commission went to work, members made cutting Social Security benefits one of their targets. One proposal that is most prominently supported by deficit hawks and Republican congressional leaders is raising the retirement age from 66 to 70.

As I’ve said, Obama has taken no position on this but he said in his radio speech that he’s
“...committed to working with anyone, Democrat or Republican, who wants to strengthen Social Security.”
It would be easy for a Republican or the commission to claim that Social Security would be “strengthened’ by raising the retirement age and saving the benefits that now go to those under 70. Besides, when have Republicans worked with Obama, except to cut spending? Today’s extremist Republicans have never supported Social Security – probably because it’s a government program that works.

That’s why my alarm bells rang when a search in Google brought me a story in Slate by Peter Bray about the Obama campaign and Social Security, way back there on September 19, 2008. It said,
“This week the Obama campaign modified his position on a sensitive issue, Social Security. Compare the current ‘Seniors & Social Security’ page with the previous version.
“Now, tell me, why, oh why, would the Obama campaign delete the following sentence: ‘[Obama] does not believe it is fair to hardworking seniors to raise the retirement age...The new page includes some reassuring language about ‘work[ing] with members of Congress from both parties to strengthen Social Security and prevent privatization while protecting middle class families from tax increases and benefit cuts.’
“Still, for those who pay attention to such things, what the new page leaves out is as important as what it puts in.”
As I said, I believe Obama has not taken a position on raising the retirement age; and I don’t know if he’s been asked. But such a proposal is anathema to most of Obama’s supporters. Ruben Burks [pdf], an official of the labor-backed Alliance of Retired Americans said,
“Can you imagine working until 70? In physically demanding jobs like construction, manufacturing and the service sector, I just don’t see how you can. And in a tough job market who would hire someone in their late 60s? Raising the retirement age is a benefit cut – plain and simple. We cannot allow it to be done.”
Social Security is keeping 20 million older and disabled Americans and over a million children out of poverty. Polls report that 77 percent of Americans an 68 percent of Republicans believe that Washington should find other ways, rather than Social Security, to reduce the deficit. And AARP’s survey shows strong majorities would prefer that their payroll taxes are raised rather than see benefits cuts.

Because Obama has yet to make his views known on raising the retirement age, AARP – the nation’s largest and most powerful organization of older Americans - has yet to take an official position on the issue which is an ominous sign. But a high-ranking source told me,
“In fact, we opposed raising the age to 70. The idea is tremendously unpopular and amounts to a serious, across-the-board benefit cut and is based on the fantasy that employers would hire people that age.
“Most have forgotten that normal retirement age goes to 67 under current law. Half of all people turning 62 claim Social Security today. Accepting a 25 percent benefit cut is mostly shortsighted in view of needs later on.”
The National Academy of Social Insurance says raising the retirement age would save about a third of the projected shortfall, but it suggests caution because low income and older workers in physically demanding jobs have shorter life spans than, say, white collar workers.

I will repeat what I asked in my column some weeks ago, how many men and women in their sixties will die while waiting for their first Social Security check.

Richard Eskow of ourfuture.org reported that while voters, Democrats and Republicans, oppose Social Security benefit cuts
"...not enough Democrats have promised they won't. Some, including the president, are avoiding the issue...The president spoke about Social Security again [on Wednesday] in Columbus, Ohio. While reassuring voters the program is 'not in crisis,' he repeated his statement that 'fairly modest changes' will stabilize it...voters will get the benefits they deserve' rather than the benefits as designed."
Might those changes mean raising the retirement age?

Liberal economist Dean Baker says that those who would slice benefits are saying, in effect,
“In the future, Social Security might have to cut benefits. To prevent these possible future benefits cuts, we must cut future benefits.”
Economist and New York Times columnist Paul Krugman charges that Republicans and the deficit commission say,
“...in order to avoid the possibility of future benefit cuts we must cut future benefits.”
Tell us this isn’t so, Mr. President.

Write to saulfriedman@comcast.net
TIME GOES BY | GRAY MATTERS: Social Security's Diamond Jubilee
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TIME GOES BY | Reverse Mortgage Part 7: Lender Conditions

by Ronni Bennett

When last we left off my tale of pursuing a HECM – an FHA-insured reverse mortgage - the appraiser had visited and I was awaiting his valuation of my home.

It is a nerve-wracking period. My broker and I had used the purchase price I paid in May to calculate an estimate of the loan amount and its costs. If the appraisal came in too low – a not unreasonable result in our volatile housing market - I might want to re-evaluate the terms of the loan I had selected and we would need to re-do the numbers.

The appraisal arrived ten days ago: almost to the dollar what I paid for it. They are so close, it is hardly worth noticing the difference. (Old woman wipes brow and issues a sigh of relief.)

My broker sent the papers I needed to read and sign here, initial there – a lot of them – and then he assembled the package for submission to the mortgage lender. A few days later, he emailed to say that the bank had approved the loan. (“Whew,” again.) Two giant hurdles leapt within one week's time.

But wait.

It's not as easy as it sounds. Nothing ever is with large bureaucracies whose goal sometimes appears to be to fell an entire forest for one transaction.

There are conditions to the approval - a couple that are, to me, arbitrarily niggling; others are just how banks spend their time; and one that is flat out unreasonable.

Certified closing statement from the sale of my Maine property. In other words, they want to know where I got the money to buy my new home. My copy won't do; it must be sent from the title company.

Certified closing statement from the purchase of my Oregon property. I have no quibble with this one.

Proof of residence in the Oregon apartment. I assume this means they suspect I'm lying about living here. They wanted the three most recent utility bills: fine.

Flood certification. This was investigated when I bought the property, but now the bank is balking because the apartment designation in the legal description is a number and the identifier used by the postal service and condominium is a letter. Again, more paper.

Condominium data. The bank wants to know how many apartment owners are delinquent in homeowner's association dues and what percentage of apartments are rented versus owner-occupied.

The condo management company charged $56 for this information. If they can't answer those two questions with three or four clicks of their keyboard, they aren't worth the money the condo is paying them. You can bet I will have something to say about that fee at the next condo meeting.

Paper trail of where I got the money to purchase my apartment in Oregon. The settlement statement from my Maine sale covers the largest part of the purchase price, but not all. I'm unwilling to send copies of my (so-called) investment account to show the source the remaining funds, so we are working out a method that doesn't reveal my entire financial life which I'm unwilling to do.
 
Letter from me explaining why I moved. This is intrusive and I don't think this is any of the bank's business, nor do they need it to approve a loan. I resent the question, but sent them a short, two sentence letter to move this process along.

These items together with the nearly one-inch thick application, including the 20-page appraiser's report, plus various checks of public records the lender itself orders seem excessive for what amounts to, in the world of too-big-to-fail banks, a loan the size of a flea secured by an apartment in an established condominium already approved for HECMs by the FHA. But one can also look at it this way:

Given the country-wide housing debacle and the bank's past history of handing out sub-prime mortgages without checking even applicant's income, the bank is being ultra-conservative now in its due diligence. I wonder why I think that's not really it. I don't recall anything near this complex in applications for past mortgages – pre-housing bubble.

The point you should take away from this, if you are pursuing a reverse mortgage, is to have all your paper ducks in a neat an tidy row for the lender. It's a pain in the ass tracking it all down.

And I still can't figure out what possible use it is to the bank to know the reason I moved. Nor what would be a negative answer that would sink the mortgage application. If there is no possible negative answer, there is no reason for the question.

The TGB Reverse Mortgage Series
Part 1: One Reason For a Reverse Mortgage
Part 2: The Basics
Part 3: Finding a Lender
Part 4: Do Not Fear HECMs
Part 5: The Mandatory Counseling Session
Part 6: The Home Appraisal
TIME GOES BY | Reverse Mortgage Part 7: Lender Conditions
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Info Long-Term Care: New Realities of an Older America

From the Stanford Center on Longevity, this report examines the major changes, challenges and decisions faced with baby boomers reaching old age and the diversity of the aging population for families, workplaces, and communities.

The implications concern young and old alike. Although many of these changes have been anticipated, the United States has relied on social and economic policies and practices designed for a more youthful population.
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Lessons from a Health Information Technology Demonstration in New York Nursing Homes

by Shana Lieberman Klinger and Scott White

The New York State Nursing Home Health Information Technology (HIT) Demonstration Project is a publicly subsidized initiative to implement comprehensive, point-of-care electronic medical records in 20 New York City nursing homes. Because of an innovative union–employer partnership, direct-care staff of the homes were heavily involved in the planning process. Union employees were assured upfront that no layoffs would result from HIT implementation, and training was a high priority in vendor selection.

All participating homes successfully replaced paper records with electronic ones, and, after the intensive pre-implementation planning period, it took less than six months on average for facilities to make this transition. Despite this shared success, variation existed between homes regarding: 1) organizational aims for adapting HIT; 2) the technology’s perceived or real effects; and 3) implementation of quality improvement efforts as a result of newly available data.
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Tuesday, August 24, 2010

Government Auditing Standards: 2010 Exposure Draft

Logo of the United States Government Accountab...Image via WikipediaAugust 2010

TO AUDIT OFFICIALS AND OTHERS INTERESTED IN GOVERNMENT AUDITING STANDARDS

GAO invites your comments on the accompanying proposed changes to Government Auditing Standards (GAGAS), commonly known as the “Yellow Book.” This letter describes the process used by GAO for revising GAGAS, summarizes the proposed major changes, discusses proposed effective dates, and provides instructions for submitting comments on the proposed standards.

Process for Revising GAGAS


To help ensure that the standards continue to meet the needs of the audit community and the public it serves, the Comptroller General of the United States appointed the Advisory Council on Government Auditing Standards to review the standards and recommend necessary changes.
The Advisory Council includes experts in financial and performance auditing drawn from federal, state, and local government, the private sector, public accounting, and academia. This exposure draft includes the Advisory Council’s input regarding the proposed changes. We are currently requesting public comments on the proposed revisions in the exposure draft.

Summary of Major Changes

The proposed revision to GAGAS will be the sixth since GAO first issued the standards in 1972. The proposed changes contained in the 2010 Exposure Draft update GAGAS to reflect major developments in the accountability and audit profession and emphasize specific considerations applicable to the government environment.

The major changes in the proposed revision were made to:
•  consolidate and reorganize the foundation and ethical principles for government audits and the standards for use and application of GAGAS (chapters 1 and 2);
•  add a conceptual framework approach for independence (chapter 3);
•  update the financial audit standards to  (1) reflect recent updates to the auditing standards issued by the American Institute of Certified Public Accountants (AICPA), where applicable, (2) more clearly identify the GAGAS requirements and guidance that supplement AICPA requirements for financial audits, and (3) consolidate the financial audit standards into a single chapter (chapter 4);

Enclosure 1 to this letter contains a more comprehensive listing of the major changes.

 Effective Dates

When issued in final form, the 2011 revision will supersede the July 2007 revision of the standards and the guidance provided in Government Auditing Standards: Answers to Independence Standard Questions (GAO-02-870G). The effective date for the 2011 revision of GAGAS will be established when the standards are issued in final form.

 Instructions for Commenting

The draft of the proposed changes to Government Auditing Standards, 2010 Exposure Draft, is only available in electronic format and can be downloaded from GAO’s Yellow Book Web Page at http://www.gao.gov/govaud/ybk01.htm.

We are requesting comments on this draft from audit officials and financial management at all levels of government, the public accounting profession, academia, professional organizations, public interest groups, and other interested parties. To assist you in developing your comments, specific issues are presented in enclosure 2 to this letter.

We encourage you to comment on these issues and any additional issues that you note. Please associate your comments with specific references to question numbers in the enclosure and/or paragraph numbers in the proposed standards and provide your rationale for any suggested changes, along with suggested revised language. Please send your comments electronically to yellowbook@gao.gov no later than November 22, 2010.

If you need additional information please call Michael Hrapsky, Specialist, Auditing Standards, at (202) 512-9535, or Jim Dalkin, Director, at (202) 512-3133.

Sincerely yours,

Jeanette M. Franzel
Managing Director
Financial Management and Assurance
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What to Tell Alzheimer’s Patients After a Trial Goes Awry - NYTimes.com

Image representing New York Times as depicted ...Image via CrunchBaseby Gina Kolata

Dr. Joel Ross, the founder and chief executive of the Memory Enhancement Centers of New Jersey, makes his living enrolling subjects in drug company clinical trials that are testing drugs for Alzheimer’s disease, among others.

So when Eli Lilly announced last week that its promising Alzheimer’s drug was making patients worse and that it was halting two large clinical trials, it seemed likely that Dr. Ross would hear from family members of his patients. Are other experimental Alzheimer’s drugs safe? they might ask. Should they get their family members out of those Alzheimer’s studies?

Not a single family member called. And Dr. Ross is not sure why.

If a study of an experimental breast cancer drug was ended because it made the cancer grow and spread, women in other breast cancer studies of similar drugs would be calling their doctors and asking what to do.

But Alzheimer’s is different. “It may reflect the incredible desperation surrounding Alzheimer’s disease,” said Baruch Brody, director of the Center for Medical Ethics and Health Policy at Baylor College of Medicine.
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Personal Health - New York Law Encourages Frank Talk on Palliative Care - NYTimes.com

Image representing New York Times as depicted ...Image via CrunchBaseby Jane Brody

Legislators have begun to recognize the medical, humanitarian and economic value of helping terminally ill patients and their families navigate treatment options as they approach the end of life.

Last week, over the objections of New York State’s medical society, Gov. David A. Paterson signed into law a bill — the New York Palliative Care Information Act — requiring physicians who treat patients with a terminal illness or condition to offer them or their representatives information about prognosis and options for end-of-life care, including aggressive pain management and hospice care as well as the possibilities for further life-sustaining treatment.
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Older Americans and People with Disabilities - Bridging the Disconnect. Information Bulletin # 320 (8/2010)

by Steve Gold

This Information Bulletin is an attempt to bridge and solidify advocates from two communities - older Americans and people with disabilities.  For many reasons, there has been a disconnect between them.

More than two years ago, we wrote "The Older Americans Act: Consumer Choice and Control over Long Term Care," (see February 9, 2007 Information Bulletin).  We reviewed how Congress' amendments to the Older Americans Act and its "Choices for Independence" began to provide services for people to remain in their homes, instead of going into nursing homes.  The Older Americans Act was for the first time really focused on community!

The OAA provided grants for States to develop a "single point of entry" for long-term care, so people would know what community-based services were available in order to avoid institutionalization.  This single point was through the "Aging and Disability Resource Centers" (ADRC).  It also adopted the "consumer model" so people could self-direct care and services.

The Older Americans Act is up for reauthorization in 2011. Yes folks, Congress will have to face whether or not the "Aging and Disability" centers will be refunded. This reauthorization will provide a forum and opportunity for these two communities to discuss how well they have worked together, how well the ADRCs are functioning, if they are serving both older Americans with disabilities and younger Americans with disabilities and what changes should occur.

There are a number of issues which we hope both communities understand and address:

1. Medicaid is the same funding stream for long-term community care and nursing homes for all people with disabilities, regardless of age.Cut-backs and reductions of Medicaid services impact every disabled person, and State legislatures' common attacks on services will hurt; people regardless of age.

2.Yes, these two communities do not agree on everything (e.g., assisted living, identifying oneself as having a disability), but there are unequivocally common interests. In an era of reductions and attacks by States on community-based services, it is critical to put aside differences and join to fight what the two communities have in common.

3. There really is power in numbers!  Can you imagine a State legislative hearing with twenty-five year old wheelchair uses holding hands with seventy-five year old wheelchair uses demanding their right to live in the community and not being dumped into nursing homes.

4.  How about next year, during the Congressional reauthorization hearings, joining forces? Tell Congress that all people with disabilities, regardless of age, want the right to receive services in their own homes.

5.  The increased Medicaid funds for Money Follows the Person grants must focus on getting anyone out of nursing homes who wants to live in the community - not just people with disabilities under 60 years old. Older Americans do not enter nursing homes because they want to; they do not have community-based services offered to them. If both communities combined their efforts, they could have a significant impact of enhancing waivers - especially in those 20 States that have not yet received MFP grants but probably will be applying for them very soon.

6. The Independent Living Centers serve many older Americans with disabilities. Yet, the AAAs and ILCs in most states keep each other at some distance. As the under 60s younger Americans with disabilities become the over 60s older Americans with disabilities, yes it really happens, the disability issues and culture will cross the age barrier. Let's hope that the people take the lead and make these organization really work together.
To not take the 2011 reauthorization as an opportunity to address these issues and to jointly work out strategies is perilous.

POWER concedes nothing without a struggle.

    Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects.

To contact Steve Gold directly, write to stevegoldada@cs.com or call 215-627-7100.
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Sunday, August 22, 2010

Genetic Markers for Living to 100 Years?: Topol on Genomics

A paper in Science, July 1, 2010, entitled "Genetic Signatures of Exceptional Longevity in Humans," by Paola Sebastiani and colleagues from Boston University has generated intense interst and controversy.

Below is a transcript of Dr. Topol's post on The Big Flap About Pathway Genomics and Walgreen's.

The topic is exceptional longevity, and can we predict it. This is an outgrowth of the Science paper by Sebastiani and colleagues, including Thomas Perls from Boston University, [published] July 1st in Science. This paper has been responsible for generating quite a controversy, which we will get into in a minute. Basically, the main finding for looking at a large group of centenarians that the New England group has accumulated over many years and doing a genome wide association study compared to a potpourri of controls --controls that came from the Illumina database, controls that included children of parents who had died in their 70s, and even a group of Parkinson’s disease patients -- so this was one of the concerns. Another one that was raised in the post-publication phase was the problem with the chips. That is, there were different chips that were tested, one that looked at 310,000 SNPs and another one that looked at 670,000 SNPs. These were not used in all the patients, so there was some lack of potential quality control regarding the SNP markers. Nonetheless, what this group concluded in Science was that using 150 SNPs, one could predict with 77% accuracy whether you would live to centenarian status, which is a pretty big jump, of course, for not only today. It is very difficult to predict longevity. Now this has come under siege. There have been reports in the New York Times. There was a Newsweek article that was entitled “The Little Flaw in Longevity-Gene Study That Could Be a Big Problem.” There are all sorts of things in the blogosphere such as “Serious Flaws Revealed in ‘Longevity Gene’ Study” [by Daniel MacArthur]. The critical issue, though, is whether these data will hold up to reanalysis. The investigators will have to redo the model that predicts exceptional longevity, taking out the SNPs that are now known to be faulty, and see whether or not, with the replication that they had, it will all hold up. Probably there will be some dilution of the effect, but some of the genes that came out of this study like TOM40, which is a known major modulator of the APOE locus adjacent to this gene, and which has already been implicated in longevity, itself were quite striking. So, we will have to see what this will turn out. This is quite a controversial study. Longevity and the science of aging is an area of fascination, and I would be interested to get your thoughts. What was really striking was that a Wall Street Journal poll that was conducted in the days after the Science paper asked how many people would like to know whether they carry the gene markers for exceptional longevity, and 75%of people (who at least read the Wall Street Journal and go onto its website and vote) wanted to get this information.
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