Good column by Michelle Singletary of The Washington Post: "The Growing Burden on Caregivers". 10/2/12.
|What is Long-Term Care Insurance?|
Long-term care insurance is a type of insurance developed specifically to cover the costs of long-term care services, most of which are not covered by traditional health insurance or Medicare. These include services in your home such as assistance with Activities of Daily Living as well as care in a variety of facility and community settings.
There is a great deal of choice and flexibility in long-term care insurance policies. You can select a range of care options and benefits that allow you to get the services you need in the settings that suit you best. The cost of your long-term care insurance policy is based on the type and amount of services you choose to have covered, how old you are when you buy the policy, and any optional benefits you choose, such as Inflation Protection. If you are in poor health or already receiving long-term care services, you may not qualify for long-term care insurance, or you may only be able to buy a more limited amount of coverage, or buy coverage at a higher “non-standard” rate.
Long-term care insurance policies have a benefit period or lifetime benefit maximum, which is the total amount of time or total amount of dollars up to which benefits will be paid. Common benefit periods for long-term care policies are two, three, four, and five years, and lifetime or unlimited coverage. Other options between five years and lifetime/unlimited coverage are also available from many companies. Most policies translate these time periods into dollar amounts and do not actually limit the number of days for which they will pay for care – just the overall dollar amount that the policy will pay. There are fewer companies today willing to offer an unlimited/lifetime policy, although some have a “high coverage option” like a $1 million lifetime limit.
With long-term care insurance, you pay premiums in amounts you know in advance and can budget for, and the policy pays – up to its coverage limits – for the long-term care you need when you need it. Typically, premiums are waived during the time you are receiving benefits.
|Coverage and Benefit Choices||Back to Top|
Policy and Benefit Choices
The following is a summary of policy and benefit choices:
- You select a daily benefit amount (for example, $100/day), which is the maximum daily amount of expenses for care the policy will pay. Most policies let you choose from $50/day to as much as $500/day. A growing number of policies specify benefits in terms of a monthly amount so that you have the flexibility to receive more care on some days (for example, when family care is not available) and less care on other days.
- Often you can choose whether you want the policy to pay the same daily benefit amount for care in all settings, or whether you want the policy to pay less for care in less costly settings, such as home care. Common choices include a home care benefit of 50 percent or 75 percent of the daily nursing home benefit amount.
- You choose a Maximum Lifetime Benefit or total lifetime amount you want the policy to provide. Policies typically offer a choice of lifetime dollar amounts – for example $100,000 or $300,000. The dollar amounts may correspond to a period of time. For example, a three-year policy at $100/day of benefits would provide you with a total of $109,500 for care. Some insurers also sell “Lifetime” or “Unlimited” coverage that has no dollar limit; you receive benefits as long as you continue to need long-term care and receive covered services.
- You choose the type of coverage you prefer – “comprehensive” or “facility care only.” Comprehensive policies cover a wider range of care settings and services including both care at home and in various types of facilities.
- Most policies today are comprehensive, but some people prefer to buy facility care only policies. These pay for care in a nursing home or assisted living facility, but not for care at home or in the community. These policies may still include hospice or respite care but only when those services are provided in a facility. Facility-care-only policies cost less than comprehensive policies, and if people prefer and have family or friends to provide care at home, they may only have the policy to reimburse them for paid care in a facility if and when they need it.
- Many policies offer additional optional benefits or “riders” allowing you to customize your coverage. One important option is Inflation Protection, which helps protect you from the rising cost of care over time. It works the same way that an inflation clause on your homeowners' insurance works: As the cost of replacing your home increases, so does the amount of insurance coverage that you maintain on the home. Most people who buy long-term care insurance opt for an inflation protection rider which builds the cost in to the starting premium, so the cost of the policy doesn’t increase simply because the value of the coverage increases with inflation. But there are many different types of Inflation Protection in long-term care insurance. Be sure to find out more about Inflation Protection options in any policy you are considering.
- Most policies offer benefits in a variety of settings, such as your home, an adult day care center, an assisted living community, or a nursing home.
Additional Costs Long-Term Care Insurance Sometimes Covers
Many policies may also pay for services or devices to support people living at home:
- Equipment such as in-home electronic monitoring systems
- Home modification, such as grab bars and ramps
- Transportation to medical appointments
- Training for a friend or relative to learn to provide personal care safely and appropriately
Some policies provide some payment for family members or friends to help care for you, but may do so on a limited basis, or only in relation to the costs that the family member incurs.
Many policies provide the services of a care coordinator, usually a nurse or social worker in your community. The care coordinator can meet with you and discuss your specific personal situation, and help arrange for and monitor your care. The care coordinator’s help is usually optional – you use it if you need and want it – and you are not limited to the providers that the care coordinator may recommend.
What Is a Typical Comprehensive Long-Term Care Insurance Benefit?
The majority of policies sold today are comprehensive policies. They typically cover care and services in a variety of long-term care settings:
- Your home, including skilled nursing care, occupational, speech, physical and rehabilitation therapy, as well as help with personal care, such as bathing and dressing. Many policies also cover some homemaker services, such as meal preparation or housekeeping, in conjunction with the personal care services you receive.
- Adult day health care centers;
- Hospice care;
- Respite care;
- Assisted living facilities (also called residential care facilities or alternate care facilities);
- Alzheimer's special care facilities; and
- Nursing homes
What Does Long-Term Care Insurance not Cover?
Like all insurance, long-term care policies have exclusions. These are listed in both the Outline of Coverage you receive before you apply, as well as in the policy after you have purchased coverage. These exclusions often follow state regulations on what exclusions are allowed. Long-term care policies typically exclude the following (even if you meet all the other requirements of the policy):
- Care or services provided by family member unless the family member is a regular employee of an organization that is providing the treatment, service or care; and the organization they work for receives the payment for the treatment, service or care; and the family members receives no compensation other than the normal compensation for employees in his or her job category;
- Care or services for which no charge is made in the absence of insurance;
- Care or services provided outside the United States of America, its territories or possessions. However, a growing number of policies now have an international care benefit that can provide care outside of the United States;
- Care or services that result from war or act of war, whether declared or not;
- Care or services that result from an attempt at suicide (while sane or insane) or an intentionally self-inflicted injury;
- Care or services for alcoholism or drug addiction (except for an addiction to a prescription medication when administered in accordance with the advice of Your Physician);
- Treatment provided in a government facility (unless otherwise required by law);
- Services for which benefits are available under Medicare or other governmental program (except Medicaid), any state or federal workers' compensation, employer's liability or occupational disease law, or any motor vehicle no-fault law
Although most policies do not pay for care you receive from a family member, friend, or other individual who is not paid to provide your care, some policies provide a cash payment for each day that you receive care from anyone, even if it is a family member or friend. These policies cost more (about 25-40% more) but allow more flexibility in using your benefit dollars. Most policies provide training and support for family and friends who provide care.
Most policies require that the facility, agency or individual providing your care meet certain minimum standards with respect to quality, safety, and training. For example, a nursing home that is not licensed but operates in a state that requires licensure, would not be covered. In states that do not require long-term care facilities or programs to be licensed, the insurance policy would typically describe the staffing, safety and other features that should be present to ensure that you receive appropriate and safe care.
Long-term care policies focus on paying for the types of services
and providers that someone needs when they cannot perform their
Activities of Daily Living on their own or when they have a Cognitive
Impairment. They do not pay for care or services unrelated to these
needs, such as hospital stays or prescription medications.
However, some policies may pay for prescription drugs provided while you are in a care facility (but not at home), and some policies pay for transportation costs to help you get to medical appointments when you are physically or cognitively impaired.
Some policies provide coverage for care related to everyday household needs such as housekeeping, laundry, meals, and managing medications, so-called “instrumental activities of daily living,” but only when you receive that help as part of the help you get from a paid care provider for assistance with Activities of Daily Living. So most policies do not pay for in-home help if all you need is help with services such as housekeeping, meals, laundry, and transportation.
Finally, long-term care policies do not pay for items provided solely for your comfort or convenience, for example a television in your nursing home room or a visit to the facility's hair care salon.
|Long-Term Care Insurance Costs and Receiving Benefits||Back to Top|
What Does Long-Term Care Insurance Cost?
Policy costs vary greatly based on your age at the time of purchase, the policy, and the coverage you select. The average annual premium cost for a policy purchased in 2007 by individual buyers, across all ages of buyers and all of the types of policies was just over $2,207. Excluding 20% of individuals who elected lifetime coverage, this represents a comprehensive policy (covering both facility and at-home care) that provides an average of 4.8 years worth of benefits, with a daily benefit amount of $160. Most policies purchased in 2007 also included some form of automatic Inflation Protection. The chart below shows the average annual premium amounts paid for long-term care insurance in 2007 overall, and for specific age groups.
Average Annual Premium amounts paid in 2007 – averaged for all ages and for specific age groups. (2008 LIMRA International, Inc.)
|Under age 40||$ 881|
|40 to 49||$1,781|
|50 to 59||$1,982|
|60 to 64||$2,249|
|65 to 69||$2,539|
|Age 70 and older||$3,026|
Designing Coverage to Best Meet Your Needs
You can customize long-term care insurance coverage to match the amount you feel you can pay. Below is an example of different long-term care insurance options – all from the same program (as illustration only) – to help you see how different coverage choices can influence the monthly premium cost you would pay. To keep it simple, the illustration only changes one coverage element at a time. The price associated with some of these changes varies by age, while for some other types of changes, the savings do not vary based on your age at the time you buy.
The basic coverage design depicted in Plan A is as follows:
- Comprehensive Coverage (Facility and at-home and community care)
- Facility care daily benefit of $150/day
- Home Health Care Benefits paid at $112/day (75% of the facility care amount).
- Elimination period of 30 days
- Lifetime coverage maximum equivalent to 5 years (or just under $275,000 for a policy paying $150/day)
- Automatic Compound Annual Inflation Protection
Age at Purchase
Note: The monthly premiums shown here are based on one long-term care insurance program’s rates and represents premium costs. Premiums for the exact same coverage described here from a different company will, for a variety of reasons, vary from the rates shown here. These monthly premiums are based on the Federal Long-Term Care Insurance Program (www.ltcfeds.com). You can use the premium calculator there to see how other types of coverage changes would impact the rates, or to explore sample rates for other ages.
Plans B through E show you different ways to reduce your premium costs compared to the coverage described in Plan A. You should examine how the compared to the coverage described in Plan A. You should examine how the premium changes for Plans B through Plans E based on the Plan A (base plan).
Plan B: Same as Plan A, except the elimination period is 90 days instead of 30 days.
Plan C: Same as Plan A, except the lifetime maximum is equal to 3 years, or just under $165,000
Plan D: Pays benefits at $100/day for facility care and, correspondingly, $75/day. All other elements remain the same.
Plan E: Same as Plan A, except it does not include Compound Annual Inflation Protection. Instead, each year you can elect to increase your coverage by a set amount (generally 5% of the prior years’ benefit amount) and you would pay for that additional amount at the time you elect it.
How Do You Pay Long-Term Care Insurance Premiums?
Different policies offer different payment options. With most policies, you pay premiums according to a schedule you select - monthly, quarterly, semi-annually or annually. You may be able to have the premium automatically withdrawn from your bank account, pension check, or paycheck (if you obtain coverage through your employer). Typically you pay premiums until you begin to receive benefits. Then premiums are waived as long as you continue to receive benefits.
With most policies, you pay premiums as long as you are not receiving benefits. However, with some policies you pay premiums only for a specified period – most often 10, 15, or 20 years. For example, with the 20-year option, you pay a monthly premium for 20 years and then your coverage is fully paid up. If you begin to receive benefits before the 20-year pay period is over, you stop paying premiums while you are receiving benefits. If you recover and have not yet paid in for all 20 years, you resume payments. With some policies you only pay premiums until age 65.
A few companies offer a “Single Pay” option, in which you pay for the insurance in one lump sum payment. While they are more expensive than traditional long-term care insurance, the advantage is that the single lump sum payment is the only premium required. These policies typically pay for long-term care expenses and also offer you the option to include a death benefit for your heirs. Some states do not allow single-pay policies.
When Are Long-Term Care Benefits Paid?
When benefits are paid is based on the policy’s “benefit trigger,” the length of the elimination period you choose, and sometimes when you start receiving paidcare.
Policies use objective measures to determine when you need long-term care. These are called ‘benefit triggers.’ Most policies use Activities of Daily Living and Cognitive Impairment as triggers for benefits. The policy pays benefits when you need help with two or more of the six Activities of Daily Living or when you have a Cognitive Impairment.
Benefits begin to be paid after an elimination period has elapsed. This is the number of days between when a benefit trigger occurs and when you begin to receive payment for services. An elimination period is like the deductible you have on your car insurance, except it is usually specified as a period of time rather than a dollar amount. As noted above, most policies allow you to choose the length of the elimination period, generally 30, 60 or 90 days. During the elimination period, you are responsible for the cost of any services you receive. Policies differ with regard to whether you are required to receive paid care or pay for services to satisfy an elimination period before benefits start.
Once you are eligible for benefits, most policies reimburse the costs you incur for covered services up to a pre-set limit. Some policies simply pay you a pre-set cash amount for each day that you meet the ’benefit trigger’ whether you receive paid long-term care services or not. These “cash disability” policies offer greater flexibility but are also significantly more expensive.
|Buying Long-Term Care Insurance||Back to Top|
Can Everyone Buy Long-Term Care Insurance?
No, having certain conditions means you may not qualify for long-term care insurance. However, insurance companies have different standards, so while you may be denied coverage by one company, another might accept you. You will probably not be approved to purchase a policy if:
- You currently use long-term care services.
- You already need help with Activities of Daily Living.
- You have AIDS or AIDS Related Complex (ARC).
- You have Alzheimer's disease or any form of dementia or cognitive dysfunction.
- You have a progressive neurological condition such as Multiple Sclerosis or Parkinson's Disease.
- You have had a stroke within the past 12 to 24 months or a history of strokes or multiple Transient Ischemic Attacks (TIAs).
- You have metastatic cancer (cancer that has spread beyond its original site).
Other health conditions are evaluated in deciding whether or not you can obtain the insurance, but these are the primary conditions that can disqualify you from obtaining insurance.
Once you are accepted for coverage, your coverage cannot be cancelled for any reason other than non-payment of premium as due, or if you have received the policy's maximum benefits. If you develop one of the health conditions listed above after obtaining coverage, you would be covered for the care you need for that condition.
The following rules apply to all long-term care insurance policies:
- Coverage cannot be cancelled or not renewed as long as you continue to pay premiums as they are due and you have not used up the maximum policy benefits.
- You have 30 days after receiving the policy to return it for a full refund.
- You have the right to designate another person to receive notice of premiums due and payments missed so you won't accidentally miss a payment.
- You have up to 65 days after the date a premium payment is due to make payment. Coverage cannot be cancelled for non-payment until after the grace period and until the “third party designee” has also been notified.
- If coverage lapses for non-payment because you were “disabled” at the time, you can restore your coverage within five months of the missed premium due date.
- If you have a group policy through your employer or other association, you can continue that coverage, unchanged, if you leave the group but want to maintain the policy.
- A spouse insured through an employer group plan may maintain coverage even after a divorce.
- Your premiums are designed to remain level over the lifetime of your coverage, and are based on your age when you first buy the policy. The insurer can change rates on a group (or class) basis, but has only a limited right to do so, and the change must apply to an entire group or class. You cannot be singled out for a rate increase.
- In most states, rate increases must be filed with and approved by the State Department of Insurance. Many states have adopted regulations that make it very difficult for an insurer to obtain approval for a rate increase.
- You typically have the right to decrease your coverage, without underwriting, if you find in the future that the current premium costs are beyond your financial means.
Things to Consider Before Buying Long-Term Care Insurance
- Don't buy out of fear or emotion.
- Don't buy more insurance than you think you may need. You may have enough income to pay a portion of your care costs and may need only a small policy for the remainder. You may have family willing and able to supplement your care needs.
- Don't buy too little insurance. That will only delay the use of your own assets or income to pay for care. Think about how you feel about having care costs that won't be covered. While you can usually decrease how much coverage you have, it is more difficult to increase coverage, especially if your health has declined.
- Look carefully at the policy you are considering. There is no “one-size-fits-all” policy.
- Does the policy pay only for room and board in a facility? If so, plan for other expenses, such as supplies, medications, linens, and other things that may not be covered.
- It costs less to buy coverage when you are younger. The average age of someone buying long-term care insurance today is about 60. For those who purchase policies offered at work, the average age at which they buy is about 50.
- Make sure that buying the long-term care insurance policy is a sound financial decision and affordable for you.
- Look at different options and talk with a professional before making a decision.
Where to Buy Long-Term Care Insurance
Most people buy long-term care insurance directly from an insurance agent, financial planner or broker. States regulate which companies can sell long-term care insurance and the products that they can sell. There are over 100 companies offering long-term care insurance nationally, however about 15 to 20 insurers sell most of the policies on the market today. The best way to find out which insurance companies offer this type of coverage in your state is to contact your state's Department of Insurance [offsite].
Another option for some people is to buy long-term care insurance offered through their employer. Many private and public employers, including the Federal government and a growing number of state governments, offer group long-term care programs as a voluntary benefit. Employers do not typically contribute to the premium cost (as they do with health insurance), but they often negotiate a favorable group rate.
If you are currently employed, it may be easier to qualify for long-term care insurance through your employer than purchasing a policy on your own. Check with your benefit or pensions office to see if your employer offers long-term care insurance.
The U.S. Office of Personnel Management has additional information about the Federal Long Term Care Insurance Program [offsite]. Check the map below to see if your state has a program to offer long-term care insurance to public employees, public retirees, and their families.
A Partnership Program is a collaboration or “partnership” among a state government, the private insurance companies selling long-term care insurance in that state, and state residents who buy long-term care Partnership policies. The purpose of the Partnership program is to make the purchase of shorter term more comprehensive long-term care insurance meaningful by linking these special policies (called Partnership qualified or PQ policies) with Medicaid for those who continue to require care.
Partnership qualified policies must meet special requirements that can differ somewhat from state to state. Most states require Partnership policies to offer comprehensive benefits (cover institutional and home services), be Tax Qualified, provide certain specific consumer protections, and include state specific provisions for inflation protection. Often the only difference between a partnership qualified policy and other long-term care insurance policies sold in a state is the amount and type of inflation protection required by the state.
Partnership policies must be certified by the State as meeting the specific requirements for the Partnership Program. State insurance departments are responsible for ensuring that individuals who sell Partnership policies are trained and understand how these policies relate to public and private coverage options.
How Do Partnership Policies Work?
A Partnership qualified policy provides you, as the purchaser, with the right to apply for Medicaid under modified eligibility rules that include a special feature called an ‘asset disregard’. This allows you to keep assets that would otherwise not be allowed if you need to apply, and qualify, for Medicaid in order to receive additional long-term care services. The amount of assets Medicaid will disregard is equal to the amount of the benefits you actually receive under your long term care Partnership qualified policy. Since these policies must include inflation protection, the amount of the benefits you receive can be higher than the amount of insurance protection you originally purchased. If you have a Partnership-qualified long term care insurance policy and receive $100,000 in benefits, you can apply for Medicaid and, if eligible, retain $100,000 worth of assets over and above the State’s Medicaid asset threshold. In most states the asset threshold is $2,000 for a single person. Asset thresholds for married couples are typically more generous.The following is an example of how a Partnership Qualified policy works. Let's say John, a single man, purchases a Partnership policy with a value of $100,000. Some years later he receives benefits under that policy up to the policy’s lifetime maximum coverage (adjusted for inflation) equaling $150,000. John eventually requires more long-term care services, and applies for Medicaid. If John's policy was not a Partnership-qualified policy, in order to qualify for Medicaid, he would be entitled to keep only $2,000 in assets. He would have to spend down any assets over and above this amount. However, because John bought a Partnership-qualified policy, if he needs to apply for Medicaid and is deemed eligible, he can keep $152,000 in assets and the State will not recover those funds after his death. However, any assets John has over and above the $152,000 would have to be spent in order for him to be eligible for Medicaid. He would also have to satisfy the income, general eligibility and functional eligibility requirements for Medicaid before he can qualify.
Partnership programs help both individuals and the state. For
individuals, it allows them to get and pay for services they need
without having to spend all of their assets. For the state, it can
decrease the amount of Medicaid dollars used for long-term care
Some Important Considerations for Consumers
- It is important to know if the long-term care insurance policy you buy is a Partnership qualified policy or not, since they can be the same as non-Partnership policies. A Partnership qualified policy is one that is certified by the State, and it must include the level of inflation protection coverage set by the State. Only if you have a Partnership policy will you be eligible for an asset disregard if and when you apply for Medicaid.
- Policies issued prior to a state Partnership Program’s effective date will not be considered Partnership-qualified; however there are circumstances under which you may be able to exchange a policy you previously purchased for one that is Partnership qualified.
- It is important to buy your Partnership qualified policy from an agent who is specially trained to sell that type of coverage. States with Partnership Programs have additional educational requirements for agents who wish to sell Partnership policies.
- It is important to note that eligibility for Medicaid is not automatic. You must still apply and meet the income, functional and general eligibility requirements of the Medicaid program in your state. The long-term care services provided by Medicaid vary by state and may not be the same as the services you are eligible to receive under your private Partnership long-term care insurance policy (for example, many state Medicaid programs do not pay for room and board costs in an Assisted Living Facility even if you are also receiving personal care).
- States that have Partnership programs are automatically considered to have “reciprocity” with each other and to honor the asset disregard you earned under a Partnership policy you purchased in a different state. However, States can “opt out” of this requirement at any time.
"Alzheimer's is a tragic epidemic that has no survivors. Not a single one," said Harry Johns, president and CEO of the Alzheimer's Association. "It is as much a thief as a killer. Alzheimer's will darken the long-awaited retirement years of the one out of eight baby boomers who will develop it. Those who will care for these loved ones will witness, day by day, the progressive and relentless realities of this fatal disease. But we can still change that if we act now."
According to the new Alzheimer's Association report, Generation Alzheimer's, it is expected that 10 million baby boomers will either die with or from Alzheimer's, the only one of the top 10 causes of death in America without a way to prevent, cure or even slow its progression. But, while Alzheimer's kills, it does so only after taking everything away, slowly stripping an individual's autonomy and independence. Even beyond the cruel impact Alzheimer's has on the individuals with the disease, Generation Alzheimer's also details the negative cascading effects the disease places on millions of caregivers. Caregivers and families go through the agony of losing a loved one twice: first to the ravaging effects of the disease and then, ultimately, to actual death.
"Most people survive an average of four to six years after a diagnosis of Alzheimer's disease, but many can live as long as 20 years with the disease. As the disease progresses, the person with dementia requires more and more assistance with everyday tasks like bathing, dressing, eating and household activities," said Beth Kallmyer, senior director of constituent relations for the Alzheimer's Association. "This long duration often places increasingly intensive care demands on 11 million family members and friends who provide unpaid care, and it negatively affects their health, employment, income and financial security."
The report also offers very personal glimpses into the lives of families who are in the throes of caring for a loved one with Alzheimer's disease, including a son who struggles to change the diapers of the mother who changed his as an infant, and a husband who watches his wife's fascination with the "lady in the mirror," not realizing the lady in the mirror is her.
In addition to the human toll, over the next 40 years Alzheimer's will cost the nation $20 trillion, enough to pay off the national debt and still send a $20,000 check to every man, woman and child in America. And while every 70 seconds someone in America develops Alzheimer's disease today, by 2050 someone will develop the disease every 33 seconds - unless the federal government commits to changing the Alzheimer trajectory.
"Alzheimer's - with its broad ranging impact on individuals, families, Medicare and Medicaid - has the power to bring the country to its financial knees," said Robert J. Egge, vice president of public policy of the Alzheimer's Association. "But when the federal government has been focused, committed and willing to put the necessary resources to work to confront a disease that poses a real public health threat to the nation - there has been great success. In order to see the day where Alzheimer's is no longer a death sentence, we need to see that type of commitment with Alzheimer's."
The full text of the Alzheimer's Association's Generation Alzheimer's report can be viewed here.
Also, a patient's loved ones were more confident about acting as surrogate decision-makers when they perceived their communication with intensive care physicians to be of high quality, said senior investigator Douglas B. White, M.D., MAS., associate professor and director of the Program on Ethics and Decision-Making in Critical Illness, Department of Critical Care Medicine.
"This is the first evidence to suggest that how a doctor guides family members through the foreign territory of critical illness may influence their ability to act as a surrogate," he noted. "Teaching doctors to be better communicators may be an important step in improving end-of-life decisions for patients. The study also reinforces the value of patients, families and friends having prior conversations about the end of life so that they can feel comfortable with their decisions about medical care."
For the study, conducted at four intensive care units at the University of California San Francisco Medical Center between 2005 and 2008, the researchers surveyed 230 caregivers who were making decisions on behalf of incapacitated patients on ventilators with greater than a 50 percent chance of dying from their illnesses.
They found caregivers who hadn't had a prior conversation with patients about treatment preferences were less confident about making decisions and it took them 40 percent longer - 33 days versus 21 days - to decide to discontinue life support.
"This prolongation of the dying process may not be in the best interest of patients and it places an enormous burden on the health care system," Dr. White said. "Health care reform will provide incentives for formal advance care planning between physicians and patients, such as the completion of advance directives and living wills. Our findings indicate that informal conversations between patients and their families may be very important for both patient-centered decisions and the family's comfort with the huge responsibility of being a surrogate."
The research team included Alyssa Majesko, M.D., of UPMC, and S. Hong and Lisa Weissfeld, Ph.D., of the University of Pittsburgh Graduate School of Public Health. The project was funded by the National Institutes of Health.
Associate Professor Jacqueline Center and Professor John Eisman, from Sydney's Garvan Institute of Medical Research, based their findings on data from the long running Dubbo Osteoporosis Epidemiology Study*.
Out of a total cohort of around 2,000, a sub-group of 121 people were treated with bisphosphonates for an average of 3 years. When compared with other sub-groups taking other forms of treatment, such as Vitamin D (with or without calcium) or hormone therapy, the longer life associated with bisphosphonate treatment was marked and clear.
These findings are published in the Journal of Clinical Endocrinology and Metabolism, now online.
"While the results seemed surprisingly good, they are borne out by the data - within the limitations of any study - and appear to apply to men as well as women," said Associate Professor Center.
"When we first looked at the figures, we thought that there had to be a fallacy, that we were missing something. One of the most obvious things might be that these are people who seek medical attention, so may be healthier and live longer. So we compared the bisphosphonate group with people taking Vitamin D and calcium or women on hormone therapy."
"The comparison against these other groups of similarly health-aware people simply confirmed that our results were not skewed by that factor."
"In a group of women with osteoporotic fractures over the age of 75, you would expect 50% to die over a period of five years. Among women in that age group who took bisphosphonates, the death rate dropped to 10%."
"Similarly, in a group of younger women, where you would expect 20-25% to die over 5 years, there were no deaths."
"The data were consistent with about a 5 year survival advantage for people on bisphosphonates."
The authors are intrigued by their findings. "We speculate that it may have something to do with the fact that bone acts as a repository for toxic heavy metals such as lead and cadmium," said Professor Eisman.
"So when people get older, they lose bone. When this happens, these toxic materials are released back into the body and may adversely affect health."
"By preventing bone loss, bisphosphonates prevent some of this toxic metal release. While we know that this is the case, we don't yet have evidence that this produces the survival benefit."
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"Osteoporosis is a big societal burden and remains a poorly understood and severely undertreated disease in Australia," said Eisman.
"Only about 30% of women and 10% of men with osteoporosis receive treatment, which is unacceptable when you consider that people could be helped, and death could be delayed by several years. There is good evidence - even without this study - that treating osteoporosis reduces fractures and reduces mortality."
"While osteoporosis is clearly under-recognised and under-treated, the findings of this study are important to better understanding the benefits of these treatments and may directly influence doctors' practice. It was unexpected and remarkable to find that not only osteoporosis but also life expectancy appear to be improved for people taking bisphosphonates," said Dr Christine Bennett, Chair of the Bupa Health Foundation Steering Committee and Bupa Australia's Chief Medical Officer.
"Bupa Health Foundation is proud to have supported this valuable research since 2005 and we see its findings as a major breakthrough that can now guide doctors' treatment decisions for these very vulnerable older people."
Like any pharmaceutical product, bisphosphonates may have unpredictable side effects in a small minority of people and should only be used for their approved purpose.
*Dubbo Osteoporosis Epidemiology Study
The Dubbo Osteoporosis Epidemiology Study is an ongoing population-based study that started in 1989 in Dubbo, a city with a population of 32,000 in regional New South Wales. The study cohort is women (1223) and men (898) over the age of 60. Approximately 60% of eligible people were recruited into the study.
Acknowledgements And Disclosure Summary
This work was supported by the National Health and Medical Research Council Australia, The Bupa Health Foundation, the Ernst Heine Foundation, and untied grants from Amgen, Merck Sharp & Dohme, Sanofi- Aventis, Servier and Novartis. There was no financial compensation paid to any of the participants in the study. The study sponsors had no role in the study design, nor the collection, analysis and interpretation of the data.
Associate Professor Center has been supported by and/or has given educational talks for Eli Lilly, Merck Sharp and Dohme, Novartis and Sanofi-Aventis. Professor Eisman has consulted for and/or received research funding from Amgen, deCode, Eli Lilly, Merck Sharp and Dohme, Novartis, Sanofi-Aventis and Servier. The other authors on the paper have nothing to disclose.
Garvan Institute of Medical Research
Bupa Health Foundation
The project - conducted by researchers at the University of Pittsburgh, University of Illinois, Rice University, and Ohio State University - is considered the first study of its kind focusing on older adults who are already experiencing atrophy of the hippocampus, the brain structure involved in all forms of memory formation. The study, funded through the National Institute on Aging, appears in the Jan. 31 Proceedings of the National Academy of Sciences (PNAS).
The scientists recruited 120 sedentary older people without dementia and randomly placed them in one of two groups - those who began an exercise regimen of walking around a track for 40 minutes a day, three days a week, or those limited to stretching and toning exercises. Magnetic resonance images were collected before the intervention, after six months, and at the end of the one-year study.
The aerobic exercise group demonstrated an increase in volume of the left and right hippocampus of 2.12 percent and 1.97 percent, respectively. The same regions of the brain in those who did stretching exercises decreased in volume by 1.40 and 1.43 percent, respectively.
Spatial memory tests were conducted for all participants at the three intervals. Those in the aerobic exercise group showed improved memory function, when measured against their performance at the start of the study, an improvement associated with the increased size of the hippocampus. The authors also examined several biomarkers associated with brain health, including brain-derived neurotrophic factor (BDNF), a small molecule that is involved in learning and memory. They found that the increases in hippocampal size were associated with increased amounts of BDNF.
"We think of the atrophy of the hippocampus in later life as almost inevitable," said Kirk Erickson, professor of psychology at the University of Pittsburgh and the paper's lead author. "But we've shown that even moderate exercise for one year can increase the size of that structure. The brain at that stage remains modifiable."
"The results of our study are particularly interesting in that they suggest that even modest amounts of exercise by sedentary older adults can lead to substantial improvements in memory and brain health," said Art Kramer, director of the Beckman Institute at the University of Illinois and the senior author.
"Such improvements have important implications for the health of our citizens and the expanding population of older adults worldwide."
Source: University of Illinois at Urbana-Champaign
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On Thursday, the panel voted 16 to 0 to recommend approval of the imaging agent, known as Amyvid, with one critical caveat: Manufacturer Eli Lilly and Co. must demonstrate that standards for interpreting brain scans that show amyloid plaques illuminated by Amyvid can be made consistent enough to routinely guarantee an accurate diagnosis.
Amyvid (florbetapir) is injected into patients who then undergo a PET scan; a negative result can help rule out Alzheimer's, according to Lilly.
Experts agreed that the test could become a critical part of spotting Alzheimer's before symptoms have taken hold, but they noted that the clinical reality of that is far from imminent.
"It may well be that amyloid imaging will join colonoscopy, mammography, etc. as mid-life surveillance tests, and that anti-amyloid interventions are most effective in the pre-symptomatic stages of Alzheimer's disease," said Dr. Sam Gandy, the Mount Sinai Chair in Alzheimer's Disease Research in New York City. However, this possibility is years away, he added.
The value for research is clear, Gandy said. "Either a spinal fluid amyloid test or an amyloid scan will help weed out non-Alzheimer's dementias in clinical trials of anti-amyloid agents. The clinical value in the short-term is less obvious."
Current medications are most effective in the early stages of Alzheimer's, and amyloid scans might identify those patients for doctors who don't have access to neuropsychological testing, Gandy said.
"A confirmed diagnosis would enable planning for the future while patients are at an early enough stage to still participate in the discussion," he said. "In the symptomatic patient, the amyloid scan would portend the onset of dementia within the next five years."
However, because there is no cure for Alzheimer's disease yet, the test might be one that is not considered worth its cost, Gandy said.
Gandy noted that the "300-pound gorilla in the room" is whether Medicare/Medicaid will reimburse such a test, even if the FDA follows its expert panel's advice and approves Amyvid. (While the FDA doesn't have to follow a panel's advice, it usually does.) "Medicare may decide that the added value does not merit reimbursement without a meaningful intervention," he said.
Also, Grandy said he doesn't expect approval until there are methods in place to train doctors in how to read these scans.
Another expert, David Loewenstein, a professor of psychiatry and behavioral sciences and neurology at the University of Miami Miller School of Medicine, said that the approval of Amyvid "will allow physicians to come to an earlier diagnosis of Alzheimer's."
What is needed is consistency for evaluating scans using the agent, he said, so that physicians "can apply a single standard and there won't be gaps between hospitals because of different readers using different methods."
Loewenstein thinks use of this new diagnostic tool will help in several ways. First, it will help researchers find effective treatments by diagnosing the disease early, although having the plaques does not always mean the patient has Alzheimer's. Second, it will identify people who can take part in clinical trials of new Alzheimer's drugs.
"There is a whole new line of drugs being formulated that will help treat the earliest stages of the disease," Loewenstein said. "We need to know who are the appropriate people with the mildest cognitive problems to get into clinical trials."
In addition, the test has value even before treatments are available in terms of helping patients prepare for the course of the disease, Loewenstein noted. "I think many people would like an early diagnosis," he said.
For more information on Alzheimer's disease, visit the Alzheimer's Association.
Seniors age 85 and older were the most likely to have reported one or more cognitive disorders (18.4 percent), compared to seniors ages 75 to 84 (6 percent) and seniors ages 65 to 74 (1.1 percent).
AHRQ found that for elderly Americans age 65 and older in 2007:
- Seniors with less than a high school education were more likely to have reported one or more cognitive disorders than seniors that were high school graduates (8.6 percent and 4.9 percent, respectively) or seniors with more than a high school education (2.7 percent ).
- Nearly 8 percent of poor seniors reported one or more cognitive disorders compared to 4.1 percent of middle and high income seniors reporting such a condition.
- Nearly 11 percent of seniors who had both Medicare and another type of supplemental public insurance reported one or more cognitive disorders, compared to 5 percent of seniors with Medicare only and 4.1 percent of seniors with Medicare and supplemental private insurance.
- Average annual health care expense for seniors reporting one or more cognitive disorders totaled $15,549 a year, compared to $9,019 for seniors not reporting any cognitive disorders.
AHRQ, which is part of the U.S. Department of Health and Human Services, improves the quality, safety, efficiency, and effectiveness of health care for all Americans. The data in this AHRQ News and Numbers summary are taken from the Medical Expenditure Panel Survey (MEPS), a detailed source of information on the health services used by Americans, the frequency with which they are used, the cost of those services, and how they are paid. For more information, go to: Person Characteristics of the Elderly Reporting One or More Cognitive Disorders, 2007 .
AHRQ News and Numbers
Misplacing car keys. Not remembering a familiar name. Some people do become more forgetful as they get older. That's a normal part of aging. Alzheimer's disease is not.
Alzheimer's disease affects approximately 5.3 million people in the U.S. Over time, Alzheimer's disease gradually destroys a person's memory and ability to learn and carry out daily activities such as talking, eating, and going to the bathroom. As the disease progresses, individuals may also experience changes in personality and behavior. Unfortunately, there are no cures for Alzheimer's disease and there is no way to predict how fast someone will progress through the stages of the disease.However, early Alzheimer's diagnosis and treatment can slow the progression of Alzheimer's symptoms. If you or someone you are caring for is suffering from Alzheimer's disease, you may want to talk with the doctor about an Alzheimer's medication called Namenda® (memantine HCl). It works in an entirely different way than all of the other Alzheimer's therapies on the market and has been shown in clinical trials to safely and effectively treat moderate to severe Alzheimer's disease.
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