For those ages 65 and older, nearly one in three individuals will fall each year. After age 85, 1 out of every 2 individuals will fall. In 2007, falls accounted for 44% of injury deaths; 76% of non-fatal injury hospitalizations. These numbers are enough to get even the calmest person steamed. We don’t like seeing anyone get upset over something a little action can prevent. Therefore, we have prepared a help guide to assist families around this potential problem.
First, are you or your loved one at risk of falling? While considering the following list ask yourself how many apply to you or your loved one?
If you checked off two or more of these factors, then a risk for falling exist. A little action can improve ones odds of avoiding being a statistic. As stated, this topic can get the calmest person steamed; so, I thought what better way to remember how to avoid falls than getting STEAMED right up front.
S: Strength—exercise and stay active. By building your strength, you are preparing your body to better control your balance and coordination. Some have suggested Tai Chi as one means of getting the necessary exercise in a low impact way.
T: Talk before you walk—you should be talking to your doctor, pharmacist, family, and friends. Tell people your concerns so they can be looking out for you. Everyone approaches life different; what they see you might not see.
E: Environment—limit those things in your life that can lead to falls. Take the list above and look around where you are and look for warning signs. In fact, make it a game and see who can spot the most hazards (lawyers are often accused of doing this already).
A: Ask for help—it seems to be human nature to resist the simple habit of asking for help. However, I have never witnessed a person asking for help and not getting it. If you need help getting up or sitting down or balancing yourself, don’t be afraid to ask for help.
M: Medications—taking multiple medications can increase your risk for falls. Also certain medications by their function or design can increase your risk for falls (i.e. sleeping pills, blood pressure medications, water pills, and pain medicine.).
E: Exam—get your eyes checked regularly. Also stay on top of your other vitals such as blood pressure and sugar. Do not solely rely on your annual visit with the doctor. Learn the warning signs of a problem and/or what test can be done at home and just DO IT!
D: Diet—staying on a healthy diet will help maintain a healthy body so you are able to exercise, avoid fluctuations in blood pressure and diabetes. Find a diet that you can enjoy and stay with it.
 From the Office of Vital Statistics, Florida Department of Health, and the Gulf Coast Falls Prevention Coalition.
We are certainly watching a Civics class in action as the Republicans in the House and Senate work toward a repeal and replacement of the Affordable Care Act (ObamaCare). The House passed its bill, the American Health Care Act (AHCA) in May. The Senate is taking the next step with its Better Care Reconciliation Act, which was introduced on June 22. Senate Majority Leader Mitch McConnell had hoped for a vote before the July 4 recess but postponed it because several Senate Republicans publicly stated they would not vote for it in its present form.
In this issue of The ElderCounselor, we will look at what is in the current Senate bill, how it differs from the House bill, why some are opposed to it, and what the future might hold. But first, let’s revisit why Republicans are trying so hard to repeal and replace ObamaCare and how they are going about it.
Why Repeal and Replace ObamaCare?
ObamaCare, you may remember, was passed by the Democrats in 2010 with no Republican support. Ever since, Republicans have campaigned on repealing and replacing the program, which was unpopular with many Americans. “Repeal and Replace” was their rallying cry to voters to help them win back control of the House in 2012, then the Senate in 2014, and finally the Presidency in 2016. If the Republicans are not able to fulfill this major promise, some may be in danger of losing their seats in the next election, as they would likely be blamed for the problems with ObamaCare if they don’t fix them. These are the political reasons.
The practical reason is that ObamaCare is self-destructing. Premiums continue to rise, deductibles and copays are so high that many cannot afford to use their plans, and insurers, who underestimated costs, are leaving markets. In 2018, many counties across the country will have no plans in the individual marketplace. Democrats admit that ObamaCare has problems and needs a major fix to survive. But they are not on board with repeal and replace of such a signature piece of legislation, and are happy to stay on the sidelines while Republicans try to find a way to pass new legislation on their own.
The Legislative Process
The normal legislative process is that a bill begins in the House, where it is written, discussed and approved by a committee before the House votes on it. If it passes the House, it is then sent to the Senate. The Senate can vote on the same bill, make amendments to the House bill, or create its own bill. Eventually, both the House and Senate must vote on the same bill, so if there are differences, members of both the House and Senate meet in committee to resolve them. Once a bill passes both the House and Senate, it is then sent to the President who can sign it into law or veto it.
As we are witnessing, this can be a messy process. Right now, there is a House bill on health care that has passed the House, and a Senate bill that has not passed the Senate. Discussions and amendments are still occurring with the Senate bill in hopes it will pass soon. The public posture is that this messy legislative process is making the bill better.
Further complicating this process is that while the Republicans have a majority in both the House and the Senate, they only have 52 Republican Senators. 60 votes are required to pass new legislation, so they are attempting to pass health care legislation through the Budget Reconciliation process. It only requires 51 votes, but it limits the legislation to budget-related items only. They would not be able to include provisions some Republicans want in a full repeal and replace bill—for example, letting insurance companies sell across state lines to increase competition, lower prices and create better plans; and allowing the government to negotiate lower drug prices. Issues like these would have to be voted on later.
For the Senate bill to pass in Reconciliation, 50 Republicans must vote for the bill, since no Democrat or Independent is expected to vote for the bill. Vice-President Pence would break the tie if needed.
How Do the Current Senate Bill and the House Bill Compare?
There are broad similarities in both bills, including the repeal of some major parts of ObamaCare, but neither is a full repeal and replace. Senate Majority Leader McConnell calls the Senate bill a “discussion draft,” as they work to get the needed Senators on board. Let’s look at how the House bill and the current Senate bill compare.
Both Bills Repeal Mandates and Most ObamaCare Taxes
Both bills call for the elimination of 1) the individual mandate that required every person to have health insurance or pay a fine and 2) the employer mandate that forces employers with at least 50 employees to provide healthcare coverage. Most of the tax increases that were imposed to pay for ObamaCare programs are also eliminated, including taxes on net investment income, insurers, drug makers and medical device manufacturers. The Senate bill keeps the “Cadillac tax” on expensive employer insurance plans, though it would be delayed until 2026.
Changes to Medicaid
Medicaid is an entitlement program that provides health care to low-income Americans, the disabled and impoverished children. ObamaCare allowed states to expand Medicaid to some low-income Americans above the poverty level, which greatly increased the number of people on Medicaid. In addition, funding for the Medicaid program is currently “open-ended,” meaning funding increases as need increases.
The problem is that these make Medicaid unsustainable. The goal for Medicaid reform in both the House and Senate bills is to rein in the Medicaid program, preserve it for those who really need it, put it on a fiscally sustainable path and reduce its future spending so that it grows more slowly. Reports of Medicaid funding cuts actually refer to reductions in future Medicaid spending. The House bill would slow the growth of Medicaid funding by $834 billion over 10 years; the Senate bill has a similar growth reduction.
Both bills roll back Medicaid expansion, but the Senate bill would do that more slowly than the House bill. The House bill ended extra federal funds for Medicaid expansion in 2020. The Senate bill begins phasing out these enhanced funds starting in 2021 and restores it to pre-ObamaCare levels by 2024.
Both bills would end “open-ended benefits,” instead of providing the states a set amount of money for each person enrolled. This could be either a per capita cap (a certain number of dollars per person) or a block grant of funds (which each state can use however it wishes). While both bills tie the caps to a rate of inflation, the Senate bill uses a lower rate of inflation than the House bill.
In light of these funding changes, states would probably put some limitations on benefits. They would also be allowed to add a work requirement for able-bodied (non-elderly, non-disabled, non-pregnant) Medicaid recipients. Also, under the Senate bill, some of the currently mandated benefits under Medicaid would be made optional.
Premiums and Premium Assistance for Older/Younger Americans
Under ObamaCare, older Americans could only be charged three times more for their insurance premiums than younger people. While that was helpful for older Americans, younger people were subsidizing them by paying more than their actual costs. Because their insurance costs were high, many young people opted not to buy insurance—causing insurers to lose money and eventually pull out of markets.
Both the Senate and House bills would allow insurance companies to charge older people up to five times more than younger people, more accurately reflecting the actual costs of their health care coverage. The Senate bill offers more help to older people who can’t afford insurance while making coverage cheaper for young healthy people, and it hopes to encourage people to voluntarily buy a policy by offering them tax credits to help pay premiums.
Currently, premium assistance (ObamaCare subsidies) is available to those with earnings up to 400% of the poverty level ($48,240). The Senate bill would limit premium assistance to those earning up to 350% of the poverty level ($42,210) through tax credits based on age, income, and geography. The House bill bases tax credits mostly on age.
Under both bills, young adults under age 26 can continue to get insurance through a parent’s plan or they can buy it independently.
Both bills ban the use of any federal funds for any health care plan that covers abortion, except in the cases of rape, incest or where the pregnancy puts the mother’s life in danger. They would also defund Planned Parenthood for one year.
Under ObamaCare, insurers were required to cover people with pre-existing conditions with no increase in cost. Under the House plan, states can receive a waiver that would let insurers charge more for some pre-existing conditions but federal money would be available to help those with expensive policies or conditions. Under the Senate plan, insurers are required to cover people with pre-existing conditions without charging them higher rates.
The original Senate bill had dropped the ObamaCare penalty on those who do not have insurance. Experts had warned that canceling the fine would lead to a sicker pool of people with insurance because young and healthy people would not face consequences for failing to purchase insurance. The Senate bill now imposes a six-month waiting period for anyone who lets their health insurance lapse for over 63 days and then wants to re-enroll in a plan in the individual market. The House bill includes a provision also aimed at those who let their insurance lapse for more than 63 days, allowing insurers to charge a 30% penalty over their premium for one year.
$2 billion has been allocated for fighting opioid addiction and helping states with treatment and response. About 30% of all opioid treatment goes through the Medicaid program, and moderates were worried that people would not be able to get treatment for their substance abuse problems. As part of the negotiations, Senator McConnell added an immediate benefit for opioid addiction.
Congressional Budget Office (CBO) Scoring
The CBO report found that, under the Senate bill, 22 million more people would be uninsured by 2026, compared to 23 million more under the House bill. Next year, 15 million more people would be uninsured under the Senate’s measure because Obamacare’s individual mandate that forces a penalty on the uninsured would be eliminated—allowing people who do not want to buy insurance to be able to drop out of the market with no penalty. By 2026, the CBO projects there would be 15 million fewer Medicaid enrollees.
In addition, average premiums for single individuals would rise by 20% in 2018 and 10% in 2019. In 2020, average premiums for single people would be about 30 percent lower than under current law. By 2026, the analysis projects such premiums will be 20 percent lower than under Obamacare.
The Senate bill would also reduce the federal deficit over the next 10 years by $321 billion. The largest savings would stem from cuts in Medicaid spending.
It should be noted that CBO predictions are just that: predictions. They can, and have been, wrong in the past and should not be relied upon as a factual basis.
As many as ten Senators have said they cannot vote for the current bill. A new Senate bill is expected in the next few days and a vote could come as early as mid-July.
Senate Majority Leader McConnell and his staff are trying to find a balance between conservative Republicans, who want a full repeal of ObamaCare and a replacement that has lower health care costs, and more moderate Republicans who want to preserve its more popular benefits. The Congressional Budget Office is reviewing legislative language, the Senate parliamentarian is reviewing processes, and Republican Senators are still submitting and discussing options that could get them to the 50 votes they need.
The deal-making process is in full swing, with the additions of opioid funding and allowing health savings accounts to be used to pay for insurance premiums. Some Senators are for potentially leaving in some taxes to pay for more generous benefits, after weeks of being criticized by Democrats for offering “tax cuts for the rich and Medicaid cuts for the poor.” Conservatives want to cut more from the regulations and many from Medicaid expansion states are uneasy about future cuts to Medicaid.
Senator Ted Cruz of Texas has offered an amendment called the “Consumer Freedom Option” that would allow insurance companies to sell any health coverage plan they wish as long as they provide one plan that satisfies the “essential benefits” mandates of Obamacare. While the Cruz amendment appeals to conservatives who want to provide consumers with lower cost options, moderates are concerned it could negatively impact those with pre-existing conditions. Supporters have suggested that federal subsidies could help ensure that premiums don’t increase for those who are seriously ill. The CBO is currently scoring this amendment.
President Trump, along with Senator Rand Paul of Kentucky and Senator Ben Sasse of Nebraska, has even offered to repeal ObamaCare now and replacing it later.
Of course, no one is going to get everything they want so there must be compromises. Majority Leader McConnell has said that if the Senate is not able to pass a bill soon, Congress will have to pass a bipartisan measure to shore up the imploding health insurance markets.
And so, the Civics lesson continues. The process is at work. And we at ElderCounsel will be watching every minute so we can keep you informed.
To comply with the U.S. Treasury regulations, we must inform you that (i) any U.S. federal tax advice contained in this newsletter was not intended or written to be used, and cannot be used, by any person for the purpose of avoiding U.S. federal tax penalties that may be imposed on such person and (ii) each taxpayer should seek advice from their tax advisor based on the taxpayer's particular circumstances.
You may already know that not getting enough good sleep can cause daytime sleepiness, an inability to make good decisions, car and other accidents, unhealthy food choices, weight gain, depression, high blood pressure, diabetes and a host of other health problems. But could poor sleep increase your risk of Alzheimer’s, too? Three recent studies are pointing us in that direction.
In this issue of The ElderCounselor, we will look at the finding of these studies and the latest advancements in the treatment and prevention of Alzheimer’s.
Boston University School of Medicine
This study, conducted by a team from Boston University School of Medicine, was published in the journal Neurology. They determined that even a small loss of the dreaming phase of sleep, called REM or rapid eye movement sleep, can increase the risk of Alzheimer’s.
The Boston team studied 321 people over age 60 who volunteered for a sleep study in the 1990s. Over the next 12 years, 32 developed dementia and of those, 24 were diagnosed with Alzheimer’s. Those who had just a little less REM sleep during the sleep test were more likely to be in the dementia group later. The difference in REM sleep was indeed slight—those who later developed dementia had only 3% less REM sleep than those who did not develop dementia. Most did not even notice the difference in their sleep.
It is not clear if the disordered sleep is a cause or an early effect of the dementia process. One of the leaders of the study, Matthew Pace, commented that, “Sleep disturbances are common in dementia but little is known about the various stages of sleep and whether they play a role in dementia risk. Our findings point to REM sleep as a predictor of dementia. The next step will be to determine why lower REM sleep predicts a greater risk of dementia.”
Washington University in St. Louis
In the second study, published in the journal Brain, a team from Washington University in St. Louis reported that sleep disruption raised levels of amyloid, the protein that clogs the brains of Alzheimer’s patients. They believe that interrupted sleep may allow too much of the compounds, amyloid and tau, to build up and that sleep might help the body clear them away.
In this study, the team allowed their group of 17 healthy adults to sleep a normal amount of time but half were prevented from getting deep sleep, called slow-wave sleep. In the mornings, their spinal fluid was analyzed. Those who had their slow-wave sleep disrupted had an increase in their amyloid levels by about 10%. The volunteers also wore sleep monitors to measure their sleep at home. Those who slept poorly for a week at home had measurably higher levels of a second Alzheimer’s associated protein called tau.
Amyloid is naturally produced in the brain and researchers know it can cause clogs called plaques. People with more plaques often have memory and thinking problems and dementia but not always, so the amyloid link is not yet entirely clear.
Dr. Yo-El S. Ju, who led this study, thinks that interrupted sleep leads to increased brain activity and increased amyloid production. Amyloid is released by brain cells all the time when they fire their synapses, but they don’t release the amyloid when they rest. Dr. Ju thinks the brain may clear out excess levels of amyloid during deep sleep.
“When people are in a nice, deep sleep, they get a period of time when, with the normal clearance mechanisms working, the levels of amyloid decrease. If levels are increased over years, they are more likely to cause the clumps, called plaques, which don’t dissolve.”
Studies in mice show it takes only an excess of about 10 percent of amyloid to cause amyloid plaques to form. This study showed that just one night of interrupted sleep can increase amyloid levels by 10 percent.
Dr. Ju’s team will next study whether treating obstructive sleep apnea, a common cause of sleep disruption, will improve people’s slow-wave sleep and affect amyloid levels.
New York University School of Medicine, Rutgers School of Public Health
In this study, published in the journal Neurology, researchers at New York University School of Medicine and Rutgers School of Public Health found that sleep apnea can lead to mild cognitive impairment (MCI) nearly 10 years earlier than in those who don’t suffer from breathing problems during sleep. And those with sleep apnea were diagnosed with Alzheimer’s an average of five years earlier than those without sleep issues.
Sleep apnea is common in older adults, affecting more than half of all men and a quarter of all women. But many go undiagnosed until they are in a car accident because they are sleepy, they develop high blood pressure or they have a stroke.
People with sleep apnea have periods during the night when their throats close up and they briefly stop breathing. It is caused by a blockage of the airway, usually when the soft tissue in the back of the throat collapses during sleep and briefly closes the throat until the person partially awakens, gasping for air. Other symptoms are loud snoring, choking and snorting while sleeping. Breathing pauses can last from a few seconds to minutes and can happen as many as 300 to 400 times a night, but the person often doesn’t wake up enough to even be aware it is happening. Instead, they wake up in the morning feeling tired.
The team reviewed the medical histories of 2,470 people aged 55 to 90 who had participated in an earlier study designed to look for markers of Alzheimer’s disease. They found that sleep apnea was associated with a much quicker decline in cognitive function. But they also found that people who got treatment declined at the same speed as people who didn’t have apnea at all. Treatments can include machines that help people breathe better as they sleep (called CPAP devices), dental appliances (for mild cases) and weight loss.
Sleep apnea leads to drops in oxygen levels, which can affect various organs in the body differently and can damage parts of the brain. Dr. Andrew Varga, an Adjunct Instructor in Medicine at New York University and co-author of the study, noted that certain neurons in the hippocampus, where much of Alzheimer’s is thought to start, are very sensitive to drops in oxygen, and sleep apnea may stress out those neurons. Also, as mentioned earlier, the disrupted sleep may prevent the brain from cleaning out the amyloids that can turn into plaques.
Recent Developments in Treating Alzheimer’s
Currently, more than 5 million Americans have Alzheimer’s. That number is expected to grow to 28 million by 2050 as our population ages. There is no cure. There are a handful of drugs on the market—Aricept, Namenda and Exelon— that were approved more than a decade ago. They can treat symptoms for a while, but they do not affect the disease itself.
There are, however, some new drugs in the works that aim to clear amyloid proteins out of the brains of Alzheimer’s patients in hopes of slowing the disease. But they are not even close to being a cure or even being on the market. The three drugs highlighted at the Alzheimer’s Association International Conference are solanezumab, aducanumab and gantenerumab.
Solanezumab, made by Eli Lilly, was first released in 2012 and didn’t seem to help patients. But developers continued to follow those in the trials and discovered that those who got the drug early seemed to be doing better, while those who got the drug later could not seem to catch up. Test scores showed very modest changes but could add to more days living at home for those treated very early. Lilly has started a phase III clinical trial, the last stage before seeking FDA approval. Results are more than a year away.
Aducanumab, made by Biogen, appears to be clearing the amyloid from the brains of patients and there is some evidence of improving test scores in patients who got the highest doses. Biogen has also started a phase III clinical trial and will test it in people who have very early Alzheimer’s disease or have mild cognitive impairment.
Gantenerumab also failed in tests, but it may be that people were not given enough of it. An analysis did show it was affecting tau protein, but higher doses have caused brain inflammation (which could indicate the drugs are working), headaches, dizziness and, in other drug trials, death.
Researchers want to offer hope, both for patients and for investors so they will continue to support the development of new drugs. But they caution that real noticeable progress in patients is still years and many dollars away. The Alzheimer’s Association is also asking Congress to fund more government research.
Can We Prevent Alzheimer’s?
There is no evidence that anything can prevent Alzheimer’s. But there are some things we can do to help slow memory loss and cognitive impairment. These include improving sleep quality, getting regular exercise, controlling blood pressure, engaging in cognitive training and changing eating habits.
Improve Sleep Quality: If you, your sleeping partner or a roommate suspect you have sleep apnea, get tested and follow through with any recommended treatment. Other sleep disrupters include restless leg syndrome, insomnia, jet lag, sleepwalking, night terrors, and stress. If your sleep suffers from any of these, talk to your doctor or a sleep specialist about steps you can take to start getting restful sleep.
Get regular exercise: Moderate aerobic exercise, like brisk walking, can have an effect on reducing cognitive impairment later in life. Experts say to aim for 150 minutes a week (30 minutes five times a week). Exercise increases the blood flow to all parts of the body, including the brain, improves physical conditioning and lifts your spirits.
Lower your blood pressure: Controlling blood pressure helps prevent heart disease. There is also evidence it can reduce the risk of memory loss and dementia because high blood pressure damages delicate blood vessels in the brain.
Engage in cognitive training: According to Dr. Ronald Peterson, an Alzheimer’s expert at the Mayo Clinic, this doesn’t mean crossword puzzles or Sudoku, although those won’t hurt. Instead, he suggests working on memory improvement techniques, called mnemonic techniques. These can include finding a new way to remember a list of grocery items; figuring a tip in your head instead of using a calculator; using new strategies that will help you process and locate information more quickly and efficiently; and working on techniques that will help you remember names and other vital information.
Dr. Peterson cautions that most “brain games” have done little more than show they make people better at playing them. He also encourages people to get out and do things, instead of sitting and watching television for hours.
Clean up eating habits: You probably know that sugary foods are not good for you. But did you also know that carbs turn into sugar in your body? And did you know that both can have devastating effects on your brain? Dr. David Permutter is a renowned neurologist. His book, Grain Brain, may provide some insights that just might change your life for the better.
Alzheimer’s is a devastating disease. There is no cure. Current medicines, when started early, only help with symptoms for a while and have no real effect on the disease itself. Therefore, we owe it to ourselves, our families, and those we serve to do everything we can to protect our brains from Alzheimer’s for as long as possible and to educate others about how to do so.
If we can be of assistance to you or the seniors you work with, please don’t hesitate to reach out.
Poor Sleep Raises Alzheimer’s Risk
Jason A. Waddell is a Board Certified Florida Elder Law Attorney who practices on the Panhandle of Florida.