Alone And Aging: Creating A Safety Net for Isolated Seniors

Phyllis Krantzman knows what she should do, but like many of her peers, the 71-year-old doesn’t know how to approach a casual acquaintance to ask who will take care of her when she needs it most.

Krantzman, of Austin, Texas, is among a growing number of seniors who find themselves alone just when aging and end-of-life care becomes real.

Unmarried, with no children, her younger sister, by seven years, died in 2014. Krantzman’s social network is limited to a handful of work colleagues and a few acquaintances.

“I’m very fearful of when I reach that place in my life when I really need help and maybe can’t take care of myself anymore,” she said. “I have nobody to turn to.”

Krantzman represents a universe that’s come to be known among geriatric specialists as “elder orphans” — seniors with no relatives to help them deal with physical and mental health challenges. Their rising numbers prompted the American Geriatrics Society this week  to unveil guidelines for a segment of these older adults who can no longer make their own medical decisions and have no designated surrogates. The nonprofit dubbed them “unbefriended” and called for a national effort to help prevent a surge among incapacitated seniors who don’t have a decision maker and face a health crisis.

Phyllis Krantzman, 71, of Austin, said buying her first computer when she was 62 "thoroughly altered my entire life" because it helped her cope with the isolation that's resulted because of her insomnia. Krantzman says she "loves TV and she loves her computer" and spends a lot of time online as she watches television. "The computer is so important to me because I have so few people in my life," she said. (Sharon Jayson for KHN)

“The computer is so important to me because I have so few people in my life,” said Phyllis Krantzman, 71. (Sharon Jayson for KHN)

Single seniors have always existed, but demographic and social changes have slowly transformed aging America. In 1900, average life expectancy was 47. Now, the combination of increased longevity, the large and graying baby boom generation, the decline in marriage, the rise in divorce, increased childlessness and family mobility has upended the traditional caregiving support system.

Among the indicators:

— A Centers for Disease Control and Prevention report this year shows the number of Americans older than 100 years old increased almost 44 percent between 2000 to 2014.

— Twenty-two percent of people over age 65 are — or risk becoming — elder orphans, according to a 2015 study by New York geriatrician Maria Torroella Carney.

— A U.S. Census report from 2014 projected by 2050 the 65 and older population to be 83.7 million — almost double the 2012 estimate of 43.1 million.

— The nonprofit Population Reference Bureau in Washington, D.C., reported earlier this year that family provides more than 95 percent of informal care for older adults who aren’t in nursing homes.

“Americans are spending less time than ever in the married state,” said Susan Brown  of the National Center for Family & Marriage Research at Bowling Green State University in Ohio, which “raises questions about who’s going to care for these people as they age and experience health declines.”

Reference Bureau demographer Mark Mather said the combination of aging boomers and family dislocation is creating “a potential caregiving crisis or at least major challenges down the road.”

The oldest boomers are now 70. With more on the horizon, the impact of smaller family size will become more pronounced: Baby boomers had fewer children than previous generations and significant numbers are childless, said demographer Jonathan Vespa, of the U.S. Census.

“As people have fewer children, there are fewer people in that next generation to help take care of that older generation,” he said.

New 2015 U.S. Census data also reflects more elders who live alone — 42.8 percent of those 65 and older. Yet new twists have emerged, such as cohousing, in which people live independently in housing clusters with a common building for meals and socializing. Such thinking, said gerontologist Jan Mutchler, of the University of Massachusetts Gerontology Institute in Boston, suggests a “shift [in] the way people are thinking about who can I rely on and who’s going to be there for me.”

Katie McGrail, 77, spent much of her working life in San Antonio or New York, finally retiring to Texas five years ago. McGrail and her friends daydream about “having these little houses around the spoke of a wheel and at center have a nurse and a good cook.”

Mary Gleason, 85, is an unmarried only child with no children. She’s lived on St. Thomas in the Virgin Islands for 51 years, where she developed a close group of “extremely supportive friends.” Most, she said, are five to 15 years younger, which proved important in January when Gleason had open heart surgery.

“That was it,” she said, noting she never talked about future care. “Now that I’m feeling so much better, I try to keep away from discussing that kind of stuff.”

It’s a mindset Mutchler knows well.

“People in general avoid planning for unpleasant things,” she said. “A lot of people don’t have wills or think about long-term care or what they would do if they needed it.”

Timothy Farrell,  a physician and associate professor at the University of Utah School of Medicine in Salt Lake City who worked on the new policies, said he would “regularly encounter patients with no clear surrogate decision maker.”

Phyllis Krantzman, 71, of Austin, stands in her kitchen after preparing her daily coffee. "My life is so much better in the last several years," she said. (Sharon Jayson for KHN)

Krantzman stands in her kitchen after preparing her daily coffee. “My life is so much better in the last several years,” she said. (Sharon Jayson for KHN)

The guidelines include “identifying ‘non-traditional’ surrogates — such as close friends, neighbors, or others who know a person well.”

Boosting social ties among elders is part of a national campaign launched last week by the AARP Foundation and the National Association of Area Agencies on Aging, a nonprofit. The aim is to combat loneliness.

Krantzman says insomnia, which has plagued her for decades, has deepened her isolation.

“I had to give up having close friends and that is one of the reasons why I find myself so alone,” she said.

Although she works part-time and lives in a government complex for low-income seniors, Krantzman said the computer she bought at age 62 has expanded her reach to connect with others.

“The computer is so important to me because I have so few people in my life,” she said. “Having the computer thoroughly altered my entire life.”

KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.

Categories: Aging, Mental Health, Public Health, Syndicate

Tags: Nursing Homes

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No Immediate Changes To Your Obamacare Coverage

To the millions of Californians who obtained health insurance as a result of the Affordable Care Act, know this: Despite the election of Donald Trump, who has promised to repeal the health law, nothing is going to happen to your coverage immediately.

In fact, open enrollment for Covered California plans continues through January 31 despite the election outcome.

“Don’t panic. The open enrollment period is set,” says Myles Pappadato, an insurance agent based in Valencia whose firm, QuoteBroker, has about 600 clients with Covered California policies. He fielded about a dozen calls the morning after the election from worried consumers.

“Don’t make any decisions based on speculation,” he adds.

Beyond that, uncertainty reigns.

In California, two major Obamacare initiatives brought health insurance to millions of people: About 1.3 million of you have plans through Covered California, the state health insurance exchange. And about 3.7 million others joined Medi-Cal, the state’s Medicaid program for low-income residents, after it expanded its eligibility criteria.

It’s not yet clear how Trump and the Republican-dominated Congress will seek to pick apart Obamacare next year — or how long that could take. An outright repeal might be difficult because it would require 60 votes in the U.S. Senate to overcome a Democratic filibuster, which means the Republicans would need the support of at least eight Democrats.

Republicans could use budget procedures instead to kill critical portions of the law, including the funding for Medicaid expansion in states like California and the federal tax credits that lower premiums for most Covered California enrollees.

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“If the subsidies go away, the vast majority of folks are not going to be able to afford their coverage. They’re struggling as it is,” Pappadato says.

Officials from Covered California, Medi-Cal and the state Health and Human Services Agency are scrambling to figure out what’s next, but the outlook isn’t good.

“I cannot provide false comfort,” says Anthony Wright, executive director of the advocacy group Health Access California. “This is a real risk for coverage that millions of Californians depend on.”

Lyn Jutronich, of San Diego, came close to tears when describing the anxiety she felt before Obamacare. Jutronich, 44, has three children under the age of 12 who are now covered by Medi-Cal. She and her husband, a contractor, have a Covered California plan and receive tax credits.

“When my child got sick or injured, I used to ask myself, ‘How am I going to pay for this?’ That burden was completely relieved” by Obamacare, she says.

“The thought of having to go back to that is just shattering.”

Before the law, Jutronich went without insurance for more than a year because she had preexisting medical conditions. At that time, insurers were not required to cover people who had previous medical problems, or they could charge them significantly more.

The premiums for the family’s insurance — with her included — would have been about $3,000 to $4,000 a month before Obamacare, so they opted to buy a plan for the kids and her husband, because of his dangerous job.

“I’m terrified that in the near future I will have to go without insurance again, and that I will again have that horrible ‘Do I really need to take my child to the emergency room today or can it wait?’ question looming in my head,” Jutronich says.

Covered California’s executive director, Peter Lee, wants to reassure consumers, saying it’s business as usual for now.

“People have some reasonable questions and those questions will take time to answer,” Lee says. “We will be working very hard to get the word out that the subsidies are available and the rules remain in place under the law.”

The Department of Health Care Services, which administers Medi-Cal, says “there are no immediate changes” to that program. It did not offer advice to Medi-Cal enrollees.

But Jen Flory, a senior attorney at the Western Center on Law & Poverty, says Medi-Cal expansion enrollees should “feel free to use their Medi-Cal. If they qualify and haven’t applied, they should still apply. No new law has been passed.”

And if you’ve been waiting to get a medical procedure or delaying an exam, “don’t put anything off,” Flory suggests.

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State Sen. Ed Hernandez, D-West Covina, chair of the Senate Health Committee, also wants Californians to keep enrolling in the coverage they’re eligible for and using the coverage they have.

“Continue doing what you’ve been doing. You have health insurance. Use it as you need it,” he says.

Hernandez expects California lawmakers to do “everything we can to protect patients to make sure they have access to health care.”

Could that include finding state money to replace any federal funding that may be cut?

“We have to ask ourselves the billion-dollar question: Does the state take on that responsibility?” Hernandez says. “That’s a discussion the state Legislature will have to have, but we’re not there yet.”

Wright, of Health Access, urges Californians to advocate for themselves in the meantime.

“Until something happens, people should sign up for the benefits and then join the political fight to keep them,” he says.

Jeffrey Kolsin, a certified public accountant in Fountain Valley, agrees that consumers need to speak up.

Kolsin, 61, and his wife receive tax credits for their Covered California policy, and the cost of their monthly premiums would double if federal funding were cut.

“What happens to people like myself who have depended on those tax credits, and all of a sudden they’re gone and now you have this huge bill?” he asks. “How do you pay for it?”

He plans to share his opinion with lawmakers, asking them not to repeal or gut Obamacare without coming up with a replacement plan first. He wants others to do the same.

“Write to the existing and new Congress members and Trump,” Kolsin says. “Fill their mailboxes, basically saying ‘Whatever you do with the Affordable Care Act, do not kill it until the day the new law goes into effect.’”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: 2016 Campaign, Ask Emily, California, California Healthline, Syndicate, The Health Law

Tags: Covered California, Medi-Cal, Open Enrollment

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France finds H5N8 bird flu in wild ducks

A severe strain of H5N8 bird flu that has hit several countries in Europe leading to the culling of thousands of poultry was detected in wild ducks in Northern France, the farm ministry said on Monday.

“A first case of highly pathogenic avian influenza H5N8 was confirmed on Nov. 26 in the commune of Marck (Pas-de-Calais), on 20 wild ducks used as callers for waterfowl hunting,” it said in a statement.

Local authorities increased surveillance in the area, the ministry said.

It said that the latest outbreak did not affect domestic farms and that provided no new case was found it should regain its international status of free of highly pathogenic avian flu on Dec. 3.

France, which has the largest poultry flock in the EU, is still recovering from a severe bird flu epidemic in southwestern France earlier this year which lead to a total halting of duck and geese output in the region and import restrictions from trading partners.

Outbreaks in neighboring countries including the Netherlands, Switzerland and Germany had prompted the ministry to impose additional precautions at farms and restricted hunting and bird gathering earlier this month.

It requested that poultry farmers located in humid regions, where the risk of transmission is higher, keep poultry flocks indoors or apply safety nets preventing contact with wild birds.

Wild birds can carry the virus without showing symptoms of it and transmit it to poultry through their feathers or faeces.

Dutch authorities destroyed some 190,000 ducks on Saturday at six farms following an avian flu outbreak.

Foie gras producers, already reeling from lost sales, expressed concern this month about the European outbreaks which come just before the year-end peak demand for the delicacy.

The H5N8 virus has never been detected in humans but it led to the culling of millions of farm birds in Asia, mainly South Korea, in 2014 before spreading to Europe.

The World Organisation for Animal Health had warned in an interview with Reuters mid-November that more outbreaks of H5N8 were likely in Europe as wild birds believed to transmit the virus migrate southward.

(Reporting by Sybille de La Hamaide, editing by Mathieu Rosemain and Louise Heavens)

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New anti-inflammatory drug reduces death of existing brain cells then repairs damage after stroke

Researchers at The University of Manchester have discovered that a potential new drug reduces the number of brain cells destroyed by stroke and then helps to repair the damage.

A reduction in blood flow to the brain caused by stroke is a major cause of death and disability, and there are few effective treatments.

A team of scientists at The University of Manchester has now found that a potential new stroke drug not only works in rodents by limiting the death of existing brain cells but also by promoting the birth of new neurones (so-called neurogenesis).  

This finding provides further support for the development of this anti-inflammatory drug, interleukin-1 receptor antagonist (IL-1Ra in short), as a new treatment for stroke. The drug is already licensed for use in humans for some conditions, including rheumatoid arthritis. Several early stage clinical trials in stroke with IL-1Ra have already been completed in Manchester, though it is not yet licensed for this condition.

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In the research, published in the biomedical journal Brain, Behavior and Immunity, the researchers show that in rodents with a stroke there is not only reduced brain damage early on after the stroke, but several days later increased numbers of new neurones, when treated with the anti-inflammatory drug IL-1Ra.

Previous attempts to find a drug to prevent brain damage after stroke have proved unsuccessful and this new research offers the possibility of a new treatment.

Importantly, the use of IL-1Ra might be better than other failed drugs in stroke as it not only limits the initial damage to brain cells, but also helps the brain repair itself long-term through the generation of new brain cells.

These new cells are thought to help restore function to areas of the brain damaged by the stroke. Earlier work by the same group showed that treatment with IL-1Ra does indeed help rodents regain motor skills that were initially lost after a stroke. Early stage clinical trials in stroke patients also suggest that IL-1Ra could be beneficial.

The current research is led by Professor Stuart Allan, who commented: “The results lend further strong support to the use of IL-1Ra in the treatment of stroke, however further large trials are necessary.”


Manchester University

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Chronic gum disease tied to risk of erectile dysfunction

By Kathryn Doyle

(Reuters Health) – Erectile dysfunction is more common in men with gum disease, according to a new review of existing studies.

Chronic bacterial infection of the gums, or periodontitis, is common and a major cause of tooth loss for adults, the authors write. The condition has been tied to a higher risk of cardiovascular disease and general inflammation, which in turn have been tied stroke and hardening of the arteries.

Stroke and hardening of the arteries are also associated with erectile dysfunction (ED).

“In our opinion, the actual biological mechanism of ED in periodontitis patients remains poorly understood,” said senior author Dr. Zhigang Zhao of The First Affiliated Hospital of Guangzhou Medical University in China.

“It might still be too early to suggest that men with ED should have their teeth checked; and that men with chronic periodontitis should worry about their sexual function,” Zhao said. “However, it might be beneficial to inform patients with chronic periodontitis about its association with ED.”

The reviewers analyzed data from five studies published between 2009 and 2014, including one randomized controlled trial. In total, the studies covered 213,000 participants aged 20 to 80.

Each study found erectile dysfunction was more common among men being treated for chronic periodontitis, particularly for those younger than 40 and older than 59. After accounting for diabetes, which can influence both gum disease and sexual function, erectile dysfunction was 2.28 times more common for men with periodontitis than for men without it, according to the report in the International Journal of Impotence Research.

“Since chronic periodontitis had been linked with several chronic disorders, it is sensible to recommend daily inter-dental cleaning to reduce dental plaque and gingival inflammation,” Zhao said. “Chronic periodontitis treatment can control or eliminate inflammation and may reduce the risk of ED.”

One study in 2013 found that treating periodontitis improves erectile dysfunction symptoms.

“Furthermore, clinicians should be aware of the potential role played by periodontitis disease in the development of erectile dysfunction,” Zhao said.

The new review did have limitations, including the fact that erectile dysfunction and chronic periodontitis are caused by similar risk factors, such as aging, smoking, diabetes mellitus and coronary artery disease. While some studies did account for diabetes, most did not account for smoking or alcohol consumption, which can also affect oral health and sexual function, the authors write.

Even after an exhaustive search, the evidence linking periodontitis and ED is limited, they write.

SOURCE: International Journal of Impotence Research, online November 10, 2016.

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Research shows mechanism that induces heart arrhythmias in diabetic mice

One of the most serious complications of diabetes, heart arrhythmias, is now on its way to be prevented and combated. Researchers from the Federal University of Rio de Janeiro (UFRJ) in partnership with investigators from University of Bonn, Universidad del Pais Vasco, Universidad de La Plata, FIOCRUZ and UNICAMP, show how the disease affects the heart and how the process can be reversed with two promising drugs. The findings have just been published in the October issue of the journal Nature Communications.

Heart problems are responsible for 65% of the deaths related to diabetes. The most common disorder in these cases is ventricular tachycardia (a dysregulation in the heart rhythm). This work, coordinated by Prof. Emiliano Medei, from the Institute of Biophysics Carlos Chagas Filho and CENABIO at UFRJ, confirms that the increase in blood glucose causes a specific inflammation, which directly affects the heart.

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To investigate this process, researchers caused diabetes in wild-type mice and mutant animals unable to produce a specific type of inflammation related to production of IL-1-beta substance. Both had similar increases in blood glucose, but only those typically inflamed- the wild-type mice — had altered heart rate. Furthermore, mutants which do not produce IL-1 beta suffered much less from arrhythmias even when under effect of caffeine or dobutamine, drugs that promote ventricular tachycardia.

The researchers found a large amount of circulating IL-1-beta and especially in the hearts of common diabetic mice. They also observed that IL-1-beta alone altered heart function when given to healthy rat hearts (without diabetes), or human heart cells. The good news is that the group also tested successfully two drugs that specifically inhibit this inflammatory process: MCC-950 and anakinra. The first blocks IL1-beta production, while the latter prevents it from having active effects in the body cells and is already being used to treat some autoimune diseases, such as rheumatoid arthritis. The team managed to even reverse the cardiac alterations in diabetic mice.

“It is noteworthy that inflammation is an important tool to fight infections, which usually ends when the ‘intruder’ is removed. In the case of diabetes, there is no infection. Persistent hyperglycemia stimulates the immune system to produce a constant inflammation, with great production of IL-1-beta — “we found inflammation to be the link between arrhythmias and diabetes”, explains Medei. “I believe that the new therapeutic tools that we propose in this study are very promising to treat the heart disease caused by diabetes” he says.


D’Or Institute for Research and Education

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Fibroblasts could provide new target for treatment of rheumatoid arthritis

A new study reveals the key role of different types of fibroblast cells in the development of rheumatoid arthritis (RA), opening up a new avenue for research into treatment of the disease. Synovial Fibroblasts (SFs) are cells that make up part of the connective tissue, or synovium, around human joints. In RA patients, SF cells cause damage by invading and attacking the cartilage and bone around the joint.
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Counseling Helps Patients Decide on Lung Ca Screening

Action Points

  • Note that this cohort study suggested that a shared decision-making session increased patients’ knowledge of the harms and benefits of CT screening for lung cancer.
  • While most patients had knowledge of the potential benefits of screening, far fewer understood the potential risks.

Smokers and former smokers eligible for lung cancer screening better understood the benefits and potential harms of screening following a single counseling and shared-decision-making visit to a screening center, researchers reported.

The Centers for Medicare & Medicaid Services (CMS) has “mandated a lung cancer screening counseling and shared decision making visit,” stated Peter J. Mazzone, MD, MPH, of the Cleveland Clinic, and colleagues. His group examined the impact of a centralized counseling and shared decision making visit for the clinic’s lung cancer screening program, and reported the results in Chest.

“We wanted to determine if there was an educational need, and if the way we delivered that education actually made a difference to our patients,” Mazzone told MedPage Today.

CMS recommends low-dose CT screening for asymptomatic smokers, ages 55-77, who have at least 30 pack years of smoking, and for ex-smokers of the same age and pack-year history who quit smoking within the last 15 years. The U.S. Preventive Services Task Force (USPSTF) has similar recommendations, but its eligible age range is 55-80.

At the Cleveland Clinic, after confirming that patients were eligible for screening, the pre-screening visit included patient education supported by a 6-minute narrated slide show, individualized risk assessment using an on-line screening decision tool, and time set aside for questions and data collection.

“Our visit was designed to have standardized elements, but also to individualize discussion while providing time for questions and answers in an effort to minimize the influence of these variables on the success of the visit,” the researchers wrote.

Pre-session questionnaires completed by patients who had the screening counseling at the clinic revealed that most patients knew little about the eligibility requirements for screening, and the potential benefits and harms of before attending the centralized counseling and shared decision-making visit.

Just 8.8% knew the correct age range of screening candidates and 13.6% knew the correct smoking eligibility criteria.

Just over half (55.5%) knew the benefits of screening, but only 38.4% could identify the potential harms, including having unneeded procedures and testing for benign disease, anxiety or distress related to test findings, radiation exposure, and overdiagnosis.

A questionnaire taken immediately after the counseling session revealed a significant improvement in knowledge about eligibility for screening and the benefits and harms of screening. A second post-session survey taken a month later found that this knowledge had waned, but remained higher than the pre-visit level.

Twenty-three of 423 patients who had the pre-screening counseling were not screened, either because they were found to have symptoms consistent with lung cancer, which made them ineligible for screening, or because they chose not to.

“I would say that about half of those patients who did not go on to be screened made the decision that screening wasn’t right for them, either because they did not want the harms or because they did not want treatment if lung cancer was found,” Mazzone said.

The patients in the study had been referred to the Cleveland Clinic for screening by their primary care physicians. The vast majority (90%) reported that these providers had discussed the benefits of screening with them, but just 19%-30% of providers discussed the potential harms.

Mazzone said primary care providers may be the only source of counseling and shared decision-making for patients considering lung cancer screening in many cases.

“We found that even though our patients were referred from their primary care providers, they still had significant gaps in knowledge, especially about harms associated with screening,” he said.

A study limitation was patient self-selection for lung cancer screening. The authors also explained that “they used a liberal definition of the benefit of screening and only asked for one potential harm from screening.”

“Patients who select screening are often more interested in preventive health and healthier at baseline,” the authors wrote. “Thus, these results may not reflect the impact of a visit with all eligible patients.”

The authors also explained that “they used a liberal definition of the benefit of screening and only asked for one potential harm from screening,” but stated that “the strengths of our study include a reasonable number of participants of variable backgrounds and very good retention of patients at all time-points.”

“A centralized counseling and shared decision making visit appears to impact knowledge of the eligibility criteria, benefit, and harms of lung cancer screening … the visit was capable of helping patients across a spectrum of education levels make value based decisions,” the group concluded.

Mazzone and co-authors disclosed no relevant relationship with industry.


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