Helpful publications

Here are a couple of publications on aging.

At the following site you will find a short down-loadable book on aging parents (or, in our case, non-parents - we are aging just like them!).

"You & Your Aging Parents: A Family Approach to Lifelong Health, Wellness & Care." Think of it as  "You & Your Aging Self."

agingredefined.org

Here is another one, on preventing fraud.  We have discussed some of this in earlier posts.  "Protect Your Pocketbook: Tips to Avoid Financial Exploitation"

 www.n4a.org

I have saved them if you need copies and cannot down-load them.

Margo, thanks for the links!

Michael

Downsizing

We recognize that there will come a time when we will need to move to more age-appropriate lodgings.   Our best guess is that time will arrive around age 75, for us.  A that age, the stairs in our home will become a challenge.  We have three flights of stairs, counting the basement, covering four levels.  The upper stairs are plenty wide, but the basement stairs, leading to the laundry (and wine cellar) are tight.  I am already finding it disconcerting to come down the stairs with my ever-present reading glasses perched on my nose.  More than once I've had trouble finding that last step.

So a move seems inevitable, and we are planning for it.  But there are some important pitfalls in downsizing that must be carefully considered.

The first in my mind is financial.  We do not consider our house a financial asset.  It is where we live.  It is where we keep our stuff.  It is not a piggy bank.  We have been fortunate enough (I like to think we have been smart enough) to have sufficient financial assets so that, with luck, we will not need to monetize the equity in our house just to survive.  Whether lucky or smart, we are blessed.  So, when we DO sell and downsize, we can, if we wish, put much or all of the resulting equity back into living facilities and to maintain our preferred lifestyle.  Just on one level instead of four.  When we are ready, we may choose to put our equity into a continuous care retirement community (CCRC) such as we have written about in earlier posts.  These facilities usually require a substantial up-front deposit, often well in excess of $100k.  Possibly much more.

Many elders and elder wanna-be's, however, are relying on home equity to supplement Social Security and other retirement funds for living expenses.  In this case, sale and downsizing may be a must.  This requires very careful planning.  Having to sell when the housing market is depressed can be devastating, so flexibility in timing is important.  Also necessary is a realistic expectation of how much equity can be monetized after investing in another place to live.  Don't forget, if you sell it, you still need someplace to live!

A smaller home may not result in lower expenses.  Most people do not move that far from their pre-retirement home (there have been studies about this), so there may not be that much difference in basic living expenses.  Food, utilities, even property taxes - the valuation on the new house may be more than the old if it is a newer construction.  And without the comfort of the old place and the old stuff, you may be seeking more entertainment and activities away from your new, boring home.

For me, the most frightening financial pitfall is trying to sell a home after already having committed to buying another or moving to the CCRC.  Having two places to live is beyond our abilities, financially and emotionally.  Best to sell first, even it if means living in a rental for 6 months or more.  In fact, living in a rental for 6 months in the community where you think you want to live will give you a chance to see if you really do want to live there.  A trial marriage, if you will, with full privileges but no long term commitment.  Not a bad strategy, in my humble opinion.

The second pitfall is stuff.  You got it.  What ya gonna do with it?  The collection of animal shaped cream pitchers.  The cow collection (don't ask).  The eight boxes of holiday ornaments and decorations.  The 200 pound band saw in the basement.  What if the new kitchen does not have enough counter space for the espresso machine.  Or enough wall space for the paintings.  You can't just leave this stuff on the curb or give it to Goodwill.  Maybe an estate sale will help, but don't expect to get a lot for the cows.  And be prepared for the trauma of disposing of so many of the markers of your life.  Things are tied to the events, places and people in our lives. They can have deep meaning.

There are, of course, people you can pay to help you with downsizing.  Moving consultants.  Downsizing consultants.  Psychiatrists.  

Now, for some good news:  for those of us with no adult children to provide long term care, there are no adult children to argue about wanting you to keep the house they grew up in or the sofa they have been storing in your den.

So, for the clientele of this blog, here is another bullet point for your planning documents.  Think about the implications before you are too feeble to think about the implications.  Plan.  Organize.  Downsize with caution.  Be well, and prosper.

Michael

A Reflection on Meditation

Much of what I write in this blog seems to be about actions and plans that are relevant to all of us who are elding, regardless of whether we have future minders lined up.  We are all subject to scams.  We all will face health issues.  And we all face the prospect of cognitive decline.  The presence of minders will perhaps ease the effects of these issues, and therefore ease out minds, but they will not prevent the issues from arising.

Peace of mind in a mind that is not mindful may be peace of mind in name only.  But, then, if the mind is gone, who cares.  Right?  Is it possible that the anticipation of dementia is worse than the actual dementia?

I believe that cognitive decline, dementia and Altzheimer's are horrible.  So horrible that they are to be avoided at all costs.  And I believe that by believing that, I will do everything I can to avoid them.  While I understand that the absence of mindfulness might be incredibly sad but not bad as we think it is,  or that it is unavoidable, I cannot BELIEVE that lest I become slack in my efforts to avoid it.  This belief is my incentive for actions that strengthen the life of the mind and prevent a mind without life.

So, what does this have to do with meditation?  Well, here it is, in a nutshell:  research has indicated that meditation can promote positive emotional states and increased "connectivity" (see below), which in turn can have the prophylactic effect of strengthening the areas of the brain that are most susceptible to cognitive decline (see way below).  And, if I interpret Maria Konnikova correctly (see also below but not as way below as before) it promotes an understanding of Sherlock Holmes, one of my literary but non-literal heros, but without the use of either a pipe or a 7% solution.   (I have included below Ms Konnikova's opinion piece from the December 16 Sunday New York Times.)

So, seriously, I still believe the best strategy for elding successfully (see earlier posts for the definition of "successful") is to prepare to be self sufficient, self directed, self controlled, self confident, self helped.  That does not mean that we should not expect to require help.  Which means, we should know that we will need help.  But we should know, in advance of need, what help will be needed, where to find it, how to pay for it, and how to be in control of it.  Know, in advance, when to sell the car.  When to move into a CCRC.  When to find a primary care physician (hint:  BEFORE moving to Florida).

Meditation, concentration exercises, memory exercises, learning a language, are all just tools to achieve the goal of being a wise respected elder instead of a whacky old coot.

Well........, maybe a little whacky.

The Power of Concentration

By MARIA KONNIKOVA

MEDITATION and mindfulness: the words conjure images of yoga retreats and Buddhist monks. But perhaps they should evoke a very different picture: a man in a deerstalker, puffing away at a curved pipe, Mr. Sherlock Holmes himself. The world’s greatest fictional detective is someone who knows the value of concentration, of “throwing his brain out of action,” as Dr. Watson puts it. He is the quintessential unitasker in a multitasking world.

More often than not, when a new case is presented, Holmes does nothing more than sit back in his leather chair, close his eyes and put together his long-fingered hands in an attitude that begs silence. He may be the most inactive active detective out there. His approach to thought captures the very thing that cognitive psychologists mean when they say mindfulness.

Though the concept originates in ancient Buddhist, Hindu and Chinese traditions, when it comes to experimental psychology, mindfulness is less about spirituality and more about concentration: the ability to quiet your mind, focus your attention on the present, and dismiss any distractions that come your way. The formulation dates from the work of the psychologist Ellen Langer, who demonstrated in the 1970s that mindful thought could lead to improvements on measures of cognitive function and even vital functions in older adults.

Now we’re learning that the benefits may reach further still, and be more attainable, than Professor Langer could have then imagined. Even in small doses, mindfulness can effect impressive changes in how we feel and think — and it does so at a basic neural level.

In 2011, researchers from the University of Wisconsin demonstrated that daily meditation-like thought could shift frontal brain activity toward a pattern that is associated with what cognitive scientists call positive, approach-oriented emotional states — states that make us more likely to engage the world rather than to withdraw from it.

Participants were instructed to relax with their eyes closed, focus on their breathing, and acknowledge and release any random thoughts that might arise. Then they had the option of receiving nine 30-minute meditation training sessions over the next five weeks. When they were tested a second time, their neural activation patterns had undergone a striking leftward shift in frontal asymmetry — even when their practice and training averaged only 5 to 16 minutes a day.

As little as five minutes a day of intense Holmes-like inactivity, and a happier outlook is yours for the taking — though this particular benefit seems to have been lost on Holmes himself, what with his bouts of melancholy and his flirtations with a certain 7 percent solution. A quick survey will show that the paradox is illusory: Holmes is depressed when there is no target for his mental faculties. Give him a project, and balance is restored.

But mindfulness goes beyond improving emotion regulation. An exercise in mindfulness can also help with that plague of modern existence: multitasking. Of course, we would like to believe that our attention is infinite, but it isn’t. Multitasking is a persistent myth. What we really do is shift our attention rapidly from task to task. Two bad things happen as a result. We don’t devote as much attention to any one thing, and we sacrifice the quality of our attention. When we are mindful, some of that attentional flightiness disappears as if of its own accord.

In 2012, researchers led by a team from the University of Washington examined the effects of meditation training on multitasking in a real-world setting. They asked a group of human resources professionals to engage in the type of simultaneous planning they did habitually. Each participant was placed in a one-person office, with a laptop and a phone, and asked to complete several typical tasks: schedule meetings for multiple attendees, locate free conference rooms, write a memo that proposed a creative agenda item and the like. The information necessary to complete those tasks? Delivered as it otherwise would be: by e-mail, through instant messages, over the phone and in person. The list was supposed to be completed in 20 minutes or less.

After the multitasking free-for-all, participants were divided into three groups: one was assigned to an eight-week meditation course (two hours of instruction, weekly); another group didn’t take the course at first, but took it later; and the last group took an eight-week course in body relaxation. Everyone was put through a second round of frenzy.

The only participants to show improvement were those who had received the mindfulness training. Not only did they report fewer negative emotions at the end of the assignment, but their ability to concentrate improved significantly. They could stay on task longer and they switched between tasks less frequently. While the overall time they devoted to the assignment didn’t differ much from that of other groups, they spent it more efficiently. They engaged, on average, in just over 40 discreet “tasks” — test-related behaviors that had a definable start and end time — spending approximately 36 seconds on each, in contrast to the 48 to 50 average tasks attempted by the other groups — with an average of only 30 seconds spent per activity. They also remembered what they did better than the other participants in the study.

The concentration benefits of mindfulness training aren’t just behavioral; they’re physical. In recent years, mindfulness has been shown to improve connectivity inside our brain’s attentional networks, as well as between attentional and medial frontal regions — changes that save us from distraction. Mindfulness, in other words, helps our attention networks communicate better and with fewer interruptions than they otherwise would.

In a 2012 study at Emory University, increased meditation practice was associated with enhanced connectivity between the dorsolateral prefrontal cortex, a part of the brain involved in attention monitoring and working memory, and the right insula, an area that is associated with how well we can monitor our own feelings and thoughts and that is considered a key waypoint between our two major attention networks, the default and the executive.

Not only could this increased connectivity make us better able to switch between tasks and monitor our own attention, but it is indicative of more effective overall management of our finite attentional resources.

Mindfulness training has even been shown to affect the brain’s default network — the network of connections that remains active when we are in a so-called resting state — with regular meditators exhibiting increased resting-state functional connectivity and increased connectivity generally. After a dose of mindfulness, the default network has greater consistent access to information about our internal states and an enhanced ability to monitor the surrounding environment.

These effects make sense: the core of mindfulness is the ability to pay attention. That’s exactly what Holmes does when he taps together the tips of his fingers, or exhales a fine cloud of smoke. He is centering his attention on a single element. And somehow, despite the seeming pause in activity, he emerges, time and time again, far ahead of his energetic colleagues. In the time it takes old detective Mac to traipse around all those country towns in search of a missing bicyclist in “The Valley of Fear,” Holmes solves the entire crime without leaving the room where the murder occurred. That’s the thing about mindfulness. It seems to slow you down, but it actually gives you the resources you need to speed up your thinking.

The difference between a Holmes and a Watson is, essentially, one of practice. Attention is finite, it’s true — but it is also trainable. Through modifying our practices of thought toward a more Holmes-like concentration, we can build up neural real estate that is better able to deal with the variegated demands of the endlessly multitasking, infinitely connected modern world. And even if we’ve never attempted mindfulness in the past, we might be surprised at how quickly the benefits become noticeable.

Until recently, our 20s were considered the point when our brain’s wiring was basically complete. But new evidence suggests that not only can we learn into old age, but the structure of our brains can continue to change and develop. In 2006, a team of psychologists demonstrated that the neural activation patterns of older adults (specifically, activation in the prefrontal cortex), began to resemble those of much younger subjects after just five one-hour training sessions on a task of attentional control. Their brains became more efficient at coordinating multiple tasks — and the benefit transferred to untrained activities, suggesting that it was symptomatic of general improvement.

Similar changes have been observed in the default network (the brain’s resting-state activity). In 2012, researchers from Ohio State University demonstrated that older adults who scored higher on mindfulness scales had increased connectivity in their default networks, specifically in two of the brain’s major information processing hubs. And while we already know that this kind of increased connectivity is a very good thing, there’s more to these particular results. The precise areas that show increased connectivity with mindfulness are also known to be pathophysiological sites of Alzheimer’s disease.

The implications are tantalizing. Mindfulness may have a prophylactic effect: it can strengthen the areas that are most susceptible to cognitive decline. When we learn to unitask, to think more in line with Holmes’s detached approach, we may be doing more than increasing our observational prowess. We may be investing in a sounder mental future — no matter how old we are.

Maria Konnikova is the author of “Mastermind: How to Think Like Sherlock Holmes” and a doctoral candidate in psychology at Columbia.

Exercise Might Beat Puzzles for Protecting the Aging Brain

The subject of this blog has been (mostly) strategies for enjoying eldrification without the assistance of those wonderful bundles of genetic material called "adult children."  The mind is a complex and wonderful tool (I have a joke about that, but later).  We are far from understanding how and why it works.  Here is a piece from the Wall Street Journal about one aspect of keeping your tool firm and sharp.

(Not THAT tool!  I mean your MIND!)

From the Wall Street Journal:

Exercise Might Beat Puzzles for Protecting the Aging Brain

http://online.wsj.com/article/SB10001424052970203630604578072723552695696.html

By JENNIFER CORBETT DOOREN

To help stave off the cognitive decline of aging, you might want to drop the crossword puzzle and head out for a brisk walk or a bike ride.

In a study published in the journal Neurology of almost 700 people born in 1936, researchers found physically active people showed fewer signs of brain shrinkage and other deterioration than those who got less exercise.

At the same time, social and intellectual activities such as visiting family and friends, reading, playing intellectually stimulating games or learning a new language did nearly nothing to ward off the symptoms of an aging brain, the study said.

"People who exercise more have better brain health," said Alan Gow, one of the study's researchers and a senior research fellow at the University of Edinburgh in Scotland.

The researchers noted, however, that "the direction of causation is unclear," meaning they couldn't tell if a healthier brain was a result of physical activity, or if people showing signs of cognitive decline weren't able to exercise. Other studies have also suggested exercise can improve brain health. Exercise increases circulation in the body and helps bring more oxygen, glucose and other needed substances to the brain.

This research is just the latest looking at cognitive function in the so-called Lothian Birth Cohort, which involves a group of people born in 1936. In 1947, almost all 11-year-old children attending school in Scotland were given intelligence and mental-health tests.

Researchers at the University of Edinburgh then recruited people from that age group who underwent those intelligence tests when they were about age 70. Participants filled out questionnaires about the types and frequency of leisure and physical activities they participated in. Physical activity was rated on a six-point scale with the lowest being "moving only in connection with necessary household chores," to heavy exercise or a competitive sport several times a week. Then at about age 73, 700 study participants were given a magnetic resonance imaging (MRI) brain scan. Brains normally shrink with age.

"What we want to do is understand more about how people age better with respect to cognitive function," Dr. Gow said.

Researchers found that higher levels of physical activity were associated with less brain atrophy, or shrinkage, and less brain damage. They found no link between brain health and leisure activities.

"We are coming to appreciate the fact that people who remain physically active are less likely to show cognitive decline," said Stephen Rao, the director of the Cleveland Clinic Schey Center for Cognitive Neuroimaging. Dr. Rao, who wasn't involved in the Scottish study, noted, however, that it looked at exercise and other activities at one point in time rather than over a lifetime. Dr. Rao is completing his own study comparing exercise and cognitive training in a different group of people.

Dr. Gow said previous research with the Lothian group suggested people who participated in more social and intellectual activities at age 70 and had better cognitive abilities were the ones who scored higher on mental ability tests at age 11.

Study participants are currently in the process of undergoing a second MRI scan now that they are age 76. Researchers said they plan to compare the two scans to see if links between exercise and better brain health hold up.


(But, doesn't using THAT OTHER tool constitute EXERCISE?)

Michael

Care by Consensus

In March I wrote about the idea of establishing a Board of Advisors to help guide us through the elding years and keep us from scams (see "Getting Scammed", March 4, 2012).  Here is a link to the New Old Age blog on the NY Times that discusses the similar concept of establishing a care committee to manage your care when there is no one else to watch out for your interests.  It was written shortly after my post (I only just now found it), so obviously they copied my idea.

http://newoldage.blogs.nytimes.com/2012/03/21/care-by-consensus/

Embedded in the blog is a link to a law firm that has drafted a Care Committee Agreement.  Here is the link:

http://cohenoalican.com/resources/118-forms/1212-care-committee.html

If you can't find it, let me know.  I have downloaded a copy.

I think it is a good idea.  The trick will be finding the right responsible advisors.

Michael

This has nothing to do with aging alone, but.....

...its just to good to pass up.  It is a video of an invocation given at a conference of Home Instead Senior Care franchisees.

The Home Instead Senior Care family network of locally owned franchise offices is an in-home care agency, to help elders in their home as they grow older.

Watch it all.  Well done.

http://stg.do/9i0c

Michael

Reverse Mortgages

This is a link to a blog post (The New Old Age, NY Times) on reverse mortgages, with a link to the full article in the New York Times. I have saved the article to read when I am older.  As of this writing, a reverse mortgage is not part of our elding strategy.  I think we can do better than that.


http://newoldage.blogs.nytimes.com/2012/10/15/growing-concerns-about-reverse-mortgages/

Michael

Guess we're not the only ones thinking about this.

Here is a link to a piece in the NY Times written by Kelly Flynn titled "But Who Will Care for Me?"  Kelly writes about finding herself in a familiar situation;  Aging, and childless.

http://www.nytimes.com/2012/10/10/booming/10story-booming.html

It is a well written piece, and she seems to be worried about how to deal with the things we have been discussing here for a while.  But what I find really interesting about this piece is the tone of the comments written by others.  Some are critical of the decision (in those cases where it is a decision and not something that just happened) to not have children.  (See my earlier post concerning our decision to not have children.)   There were also comments such aas the following:

Sorry, but anatomy is destiny.
A woman was given a womb to hold a child.
A woman was given breasts to nurture that child.
A woman who makes a decision not to have any children becomes a study in tragedy and sorrow when she ages in an empty home.
So sad. So tragic. So selfish.

Are we talking about a woman, or a horse?

Others commented on the unreliability of children to provide happiness and security as their parents eld.  Some where happy to have husbands and families, some happy that they did not have to suffer the indignity of an ailing or un-faithful husband or ungrateful kids.

I guess my point is that in thinking about eldering without childering, there is a danger in getting hung up on decisions of the past, to foal or not to foal, circumstances that may have prevented or encouraged foaling, an involuntary act of conception that resulted in unanticipated or premature foaling.  Hey, snap out of it!  Looking back, looking for regrets, for missed opportunities, for things that might have been had not something else been instead, only promotes sadness.  And sadness does not get us where we want to go.

Here we are looking for strategies that will result in a happy elderhood.  I propose that an important aspect of an effective strategy is the ability to look forward, with enthusiasm and anticipation, not fear or regret.

• Yes, I will likely move into assisted living some day.
• I will meet new people there.
• Some will be incredibly annoying
• Some will not appreciate my humor or like my curried skittles.
• Some will become my best friends.
• I will cry when friends pass on.
• I will look back on our times together and smile, not with regret but with gratitude that we had a some great, interesting times.

Attitude is key.  Developing the habit (Oh, God, not with the HABITS again!) of a positive outlook is key.  If you must look at the movie of your past, think of it as a comedy.  Smile.  Laugh.  Then look forward.

"We did not have any kids.  I did have a foal once.  Named him Hargus.  Boy, what a stupid kid I was back then.  Hey, Kelly, want a beer?  Lets play some dominos!"

Michael

The Keys, Please.

Below is a link to an NPR piece (yes, I listen to NPR for news, but I do browse the "other medias" as well) on the pending surge in us older folks out on the streets driving our 20 year old Audi's.  The serious question (one I have touched on in these posts before) is, "when it comes time to give up the keys, who will tell us, the tellees, who have no tellers handy in the family, that time is up?"

Bunni Dybnis, a social worker at the Los Angeles-based geriatric care service LivHome, says this is typically how older drivers decide to give up the car keys: Their child or grandchild intervenes. "I could probably say it's 99.99 percent not the older adult saying, 'I want to stop driving; help me,' " says Dybnis, because giving up driving feels like giving up one's independence.

Here is what I plan to do.  I have already established the HABIT of getting an annual physical exam by my primary care physician.  My next exam is some time in March or April (it is iBuried somewhere in my iPhone iCalendar).  At that exam I intend to ask my PCP to incorporate the following steps into the exam program:  a)  discontinue doing a P.S.A. exam at age 65, and b) if possible, in this state, if he sees any signs of diminished capacity that could affect my ability to drive safely, to prescribe a driving test or class.  Since I also see a neurologist once a year, I will ask her to do b) as well (she has never offered to do a), much to my relief).

Actually, first I will ask them if it is wise to ask them to do this, as I don't want to screw up my medical records and insurance.  But I think this is the second most important thing to do about driving skills.  The first is to develop the HABIT of objectivity concerning driving.  Even now, in my prime, I can look into the rear view mirror and tell myself "That other driver was NOT an asshole.  I was the asshole in this situation.  DON'T DO THAT AGAIN!"

This habit is reinforced by SheWhoMustBeObeyed, who frequently says this, sometimes just the second sentence, even when I am not driving.

The link:

http://www.npr.org/blogs/health/2012/10/08/162392507/when-should-seniors-hang-up-the-car-keys?ft=3&f=111787346&sc=nl&cc=es-20121014

Michael

A Matter of Context

What is the difference between being observed, and being admitted?

Observation:  an activity of a living being, such as a human, consisting of receiving knowledge of the outside world (including knowledge of other humans) through the senses, or the recording of data using scientific instruments.

Admission:  the act of allowing to enter; entrance granted by permission, by provision or existence of pecuniary means, or by the removal of obstacles: the admission of aliens into a country.  Or, right or permission to enter: granting admission to the rare books room.

This is an important distinction when it comes to being precise about the written or spoken word.  It is even more important when these terms are applied by your local friendly hospital.

Note:  In a hospital context, it is possible to be observed after being admitted.  In fact, it is unavoidable.  When admitted to a hospital, ones every move is observed.  Movements are of particular import.  The absence of an expected movement can indicate a blockage (the state of being blocked;  an obstructed condition: the blockage of the streets by heavy snows.  The blockage of bowls by impacted.......stuff).

Note:  In a hospital context, it is possible to be observed without being admitted.  One may, in fact, be physically "in" the hospital, having one's blockages examined by all sorts of scientific instruments, passing knowledge to one's doctor, being "in" without being "admitted", without permission to say one is "here" more than momentarily, even thought a momentary observation might last days, even weeks.

In a hospital context, your doctor may allow you "in", without an admission that you have been admitted "in", that you do not belong "in" for anything other than to be "observed".  If you happen to be on Medicare, and you happen to have something wrong that will require further assistance or treatment, or "rehabilitation" (I'll not burden you with another definition), but the hospital is only "observing" you, not treating you, then Medicare MAY NOT PAY FOR YOUR REHABILITATION.  You will, like Arlo Guthrie, be doomed to answer, possibly forever, the question "Kid, have you been rehabilitated?" with a resounding "no, officer, I don't have the do-re-me."

Case in point:  Martha Leyanna, Newark, Delaware, fell.  Went to the ER.  Was placed in the hospital. Stayed for eight (8) days (I guess it took a few days to figure out that she could not walk).  Spent 40 days in a rehabilitation center (to which her doctor no doubt sent her after determining that mere observation was not helping her get back on her feet).  When the $11,000 bill for rehab arrived, her Medicare insurance would not pay it.  Why?  Because she had only been observed for 8 days.  She had not been admitted.

Under Medicare rules, they will pay for the first 20 days of rehab in a skilled nursing care facility, but only if the patient has spent at least three (3) full days in the hospital as an admitted patient. So for Martha, who was "in" the hospital for eight (8) days, receiving all the care that any "admitted" patient would receive, in fact the EXACT SAME CARE, the fact that none of those eight days of hospital care  were as an admitted person meant that she was not covered.

Now, there are those who would say that she should pay her own way lest she become one of those 47% of Americans who feel entitled to food stamps and health care, who do not take personal responsibility for their lives, who take advantage of the insurance they have already paid for to in order to somehow sponge off the rest of us.  As a politically agnostic blogger, I take no position on that.  But, given the rules as they are, if you are insured by Medicare, it is important you know the rules.

So here is what AARP says to do if you are "in" a hospital:

1. Ask about your status daily.  Your status can change at any time, without your knowledge.
2. If you are being "observed," ask the hospital doctor why.  Ask him to have the committee that decides this status to reconsider.
3. Ask you own doctor (if you can remember who he/she is) the same thing.
4. If you have been "observed" but need rehab care, ask your doctor if the rehab care can be done at your home so it costs less.
5. Worst cast scenario:  Rehab center needed, Medicare won't pay.  Then:
1. "Following the instructions given in your quarterly Medicare Summary Notice, formally appeal the ruling.  Explain that the basis for your appeal is that you should have been classified as an inpatient during your stay at the hospital."  Simple.
2. If denied, follow the instructions on your denial letter to appeal to a higher level.  Simple.
3. Yeah, right.  I've got macular degeneration and can't read, have no idea what pile of crap my Medicare Summary Notice is in, am not sure how to get back to my home to find it even if I COULD walk.  Yeah, right.

I guess it boils down to this:  If you are conscious when entering the ER, be sure to ask your doctor what your status is, why it is what it is, why he thinks why it is what it is is the right way to think should be, and if you are only being "observed", why you should not just go home to die instead of enduring the inconvenience of being "in" without belonging "in".  If you are conscious.  And aware.  Doesn't matter if you are 85 years old and believe that the women who says she is your daughter is some street walker that only wants to get in your underwear and steal you watch (that is where I always keep mine)(She IS in fact a street walker, because, now I remember, I DON'T HAVE ANY CHILDREN).  Just take some personal responsibility and fess up:  "Really, I can walk, I just don't CHOOSE to."
 
Or ask the daughter of the patient next to you (daughter, not son - you already know my feelings about sons and their worth when it comes to caring for elderly parents) to help, because frankly that fall and the concussion make you dizzy every time you even think about getting out of bed and walking to the bathroom.

Seriously, I wish there were better answers.  I wish the system included patient advocates that could protect old, confused, lonely people.  The American Medical Association has told Medicare that it supports the abolition of the three (3) day rule.  Others have lobbied to do away with the "observation" classification.  But when the AARP asked officials at the Centers for Mediare & Medicaid Services to comment for a recent article, they declined to be interviewed, citing ongoing lawsuits.

Lets hope the suits win.

A Pasticcio

Some interesting odds and ends that help put eldering in perspective:

¢ The average American aged 65 or older makes 8 visits per year to a doctor, a hospital and/or an emergency room, i.e., once every 1 ½ months (source: Center for Disease Control).

¢ 1% of the US population accounts for 21.8% of all health care expenditures.  5% of the population accounts for 49.5% of all health care expenditures.  15% of the population accounts for no health care expenditures (source: National Institute for Health Care Management).

¢ 50% of the US population accounts for just 2.9% of all health care expenditures (source: National Institute for Health Care Management).

¢ Americans born in 1946 or later will have to work at least until age 66 (to as much as age 67 for individuals born in 1960 or later) to achieve full retirement benefits from Social Security.  Once that retiree hits his/her unique full retirement age, postponing receipt of the retirement benefits will increase the payout by +8% per year (source: Social Security Administration).

¢ 62% of American adults believe the greatest risk to the success of their retirement years is living too long (source: MetLife Mature Market Institute).

¢ 70% of retirees surveyed in 2007 (i.e., 5 years ago) were "very" or "somewhat" confident that they would have a "comfortable" retirement.  Only 52% of retirees feel that way in 2012 (source: Employee Benefit Research Institute Retirement Survey).

¢ The life expectancy at birth of an average American was 62.9 years in 1940, 5 years after Social Security was created in 1935.  Life expectancy is 78.7 years today (source: Center for Disease Control).

¢ 25% of American families headed by a retired person do not pay off their outstanding credit card balance each month.  46% of families headed by an individual that works as an employee of a firm (i.e., not a business-owner) do not pay off their outstanding credit card balance each month (source: Federal Reserve).

¢ 51% of over 1,500 American households surveyed in May 2012 believe they are "behind" in their accumulation of retirement savings (source: Consumer Federal of America).

¢ 2 out of every 5 American males that live to age 65 will survive at least another 20 years to age 85 (source: Social Security).

¢ The average single-family home nationwide peaked in value on 6/30/07 but has dropped by 17% from that maximum value as of 6/30/12 (source: Office of Federal Housing Enterprise Oversight).

¢ An estimated 7,600 Americans will turn 65 years old each day this year (2012).  An estimated 11,400 Americans will turn 65 years old each day by the year 2029 (source: Government Accountability Office).

¢ A present value (PV) amount of $196,000 is required to fund a $1,000 per month payment for 20 years with a 3% annual increase for maintenance of purchasing power assuming a +5% annual rate of return is maintained into the future.  The PV amount is $269,000 if the required payment period is 30 years.  The calculations ignore the impact of taxes and are for illustrative purposes only and are not intended to reflect any specific investment alternative (source: BTN Research).

¢ If the fifth bullet is recalculated using a +6% assumed rate of return (+1% increase), only $179,000 is required to fund the 20-year payout and $237,000 is required for a 30-year payout (source: BTN Research).

¢ Social Security benefits were not subject to any federal income taxation until 1984.  Depending upon your adjusted gross income, as much as 85% of your social security benefits could be federally taxable today.  The first social security benefit checks were paid in 1937 (source: Social Security).

Morningstar: Do You Have a Viable Plan for Long-Term Care?

Forget gas prices, college costs, and cable bills. If you want an example of skyrocketing inflation, look no further than long-term care insurance premiums, which have jumped between 6% and 17% during the past year alone, according to the American Association for Long-Term Care Insurance. Some existing policyholders have been confronted with the choice of swallowing higher premiums or accepting benefit cutbacks, and during the past few years major providers such as 

About the Author

Christine Benz is Morningstar's director of personal finance and author of 30-Minute Money Solutions: A Step-by-Step Guide to Managing Your Finances and the Morningstar Guide to Mutual Funds: 5-Star Strategies for Success. Follow Christine on Twitter: @christine_benz and on Facebook.

Contact Author | Meet other investing specialists

 Prudential Financial (PRU)and  MetLife (MET) have stopped writing new long-term care policies altogether. Not only are interest rates low, meaning the insurers can't earn much on the premiums and have to charge more to compensate, but insurers have had to cover larger claims for long-term care than they anticipated when they initiated the policies.

Given that inhospitable backdrop, many consumers are opting to go without long-term care insurance altogether. Wealthier individuals might decide to foot the bill from their own savings when and if they need long-term care. Less-affluent consumers, meanwhile, may conclude that forking over long-term care premiums simply isn't a good use of their assets if they're also behind on being able to meet basic needs during retirement, or they have missed the window to purchase long-term care at a reasonable price. (By the time a person hits his or her mid- to late 60s and might also be experiencing health issues, the policies can be exceptionally costly.) For such people, Medicare and Medicaid might be their only options should they need long-term care.

But Medicare only covers long-term care needs under a limited set of circumstances and for a short period of time. Qualifying for Medicaid, meanwhile, can be a devilishly complicated process, requiring an individual to exhaust most of his or her financial assets and also limiting the type of care that's available. If relying on these programs is your fallback plan, it's a good idea to understand the ins and outs of them well before you get close to needing them. Ditto if you help oversee your parents' finances and you expect they might have long-term care needs down the line.

Below are some of the key factors to bear in mind.

Medicare Not Much of a Safety NetMany individuals assume that Medicare will cover their long-term care, taking comfort in the fact that Medicare benefits are not needs-based, so people don't need to deplete their assets to qualify. But there are actually tight limits on what type of care the program will provide and when. Medicare covers the first 20 days in a skilled nursing facility following a three-day hospital stay, provided the person needs skilled care; for the next 80 days, Medicare picks up a portion of the bill. It may also provide short-term home health care for those recovering from an illness or injury as well as hospice care for individuals in the last stage of a terminal illness. Medicare doesn't cover extended, open-ended long-term care--what's called custodial care to help an individual carry out basic activities like bathing, eating, getting dressed, and so forth.

What Medicaid Will (and Won't) ProvideLong-term care benefits are available through Medicaid to low-income individuals who can demonstrate financial need. (More on that below.) Those benefits do cover long-term care for an indefinite period, but you'll be limited to certain facilities, which might not be as geographically well-situated or have the same amenities as others. One other important limitation to obtaining long-term care coverage via Medicaid: In-home care, which many people prefer over moving to an external facility, is typically not an option.

Punitive Lookback ProvisionFor many elderly people, the big nightmare of long-term care is that paying for it could gobble up the financial assets they had hoped to leave for their spouse, children, or grandchildren. And unfortunately, qualifying for Medicaid requires seniors to spend down nearly all of their assets first. Specific rules regarding Medicaid eligibility vary by state, but in many states, allowable assets top out at around $2,000; individuals are typically also allowed to retain some level of home equity, often up to $500,000.

At first blush, acting preemptively to shield those assets, either by transferring ownership to a spouse, gifting to loved ones, or setting up trusts might seem like a good workaround. But even if you can get comfortable with the idea of taking extraordinary measures to qualify for Medicaid (and some people cannot), there are some important caveats to bear in mind.

In order for the spouse in need of long-term care to be eligible for Medicaid, the healthy spouse is typically only able to retain a house, a car, and a modest level of assets equal to one half of the couple's assets, subject to minimum and maximum thresholds. (The maximum for 2012 is $113,640.) So putting assets in a spouse's name won't solve the problem, which becomes particularly acute if the spouse is much younger and will need assets for many more years.

Gifting assets to other loved ones also is not a viable solution if the elderly person expects to need long-term care anytime soon. If the assets are gifted five or fewer years before the individual applies for Medicaid, a penalty period applies, during which the individual is ineligible for government aid. The length of that penalty period is determined by dividing the assets that were gifted by the monthly cost of nursing home care in your state. So if you gift $100,000 to your son, and nursing care costs $5,000 per month, the penalty period would be 20 months. Moreover, the penalty period would only begin after you were already in a nursing home, had applied for Medicaid, and had spent down your assets to Medicaid-eligible levels. At that point, your only recourse would be to sell your home--which you'd otherwise be allowed to keep--or hope that one of your gift recipients would fit the bill for you until Medicaid kicked in. Needless to say, the laws are set up to deter such transfers.

The same five-year lookback provision applies to assets stashed in revocable trusts, as well--that is, trusts that can be changed after they were initially set up. It's possible to put the assets inside a revocable trust and avoid the lookback provision. You and your spouse would be entitled to any income from the trust, but the principal would pass to your heirs. Elder-law attorneys frequently set up such trusts as a means of helping families retain assets while also allowing for Medicaid eligibility, but the process can be costly. Also, you'd need to weigh whether setting aside money for your kids outweighs the added flexibility you'd have if you were to use that money for your own care. For example, you'd have greater latitude to opt for long-term care in your home or pick a facility near your spouse's or children's homes.

TakeawaysGiven the rising cost of long-term care, as well as long-term care insurance, the problem of paying for it is likely to be with us for the foreseeable future. That argues for investigating long-term care insurance while you're young enough for it to be affordable. Alternatively, if self-insuring is part of your plan, make sure you've calculated how much you could need in a worst-case scenario, and segregate that amount from the assets you'll use to fund your in-retirement living expenses. Finally, if you expect that you may need to rely on Medicaid to help cover the cost of long-term care, but you'd also like to pass assets to your children, the asset-transfer penalties outlined above should provide a strong incentive to gift to your loved ones preemptively, well before your need for long-term care arises. I'll be writing more about these and other issues related to long-term care in the future.

Morningstar - 40 must-know statistics

How to pay for long-term care is on your mind, judging from the valuable set of reader comments below last week's article about the limitations of Medicare and Medicaid coverage for long-term care. Readers shared their personal experiences as caregivers of elderly relatives and also discussed whether they had purchased long-term care insurance for themselves or were doing without.

About the Author

Christine Benz is Morningstar's director of personal finance and author of 30-Minute Money Solutions: A Step-by-Step Guide to Managing Your Finances and the Morningstar Guide to Mutual Funds: 5-Star Strategies for Success. Follow Christine on Twitter: @christine_benz and on Facebook.

Contact Author | Meet other investing specialists

Making a sound decision about whether to opt for long-term care insurance involves weighing the probabilities. Is it worth it to pay the premiums for many years--and risk premium increases or benefit cutbacks along the way--in exchange for the peace of mind that your nest egg won't be wiped out to pay for your care at the end of your life? What if you never need long-term care, or only need it for a limited time?

Ultimately, the "right" decision will be evident only in hindsight. And in any case, the decision to buy long-term care insurance is a highly personal choice that will revolve around your health and your financial wherewithal, among other factors.

To make good judgments about whether to buy this type of coverage, it's important to arm yourself with the facts about what it's likely to cost, as well as to gauge how likely you are to need care in a long-term setting, and for how long. What follows are some statistics to aid in your decision-making. My aim was to seek the most current statistics available from objective sources. (Insurers and insurance associations crank out a staggering number of statistics about the likelihood you'll need long-term care and how much you'll pay, but it's hard to ignore that they have a horse in the race over whether to buy long-term care insurance.)

37 million: Number of Americans age 65 or older in 2005.

81 million: Expected number of Americans age 65 or older in 2050.

9 million: The number of Americans over age 65 who need long-term care in 2012.

12 million: The number of Americans expected to need long-term care in 2020.

40%: The percentage of the older population with long-term care needs who are poor or near-poor (income below 150% of the federal poverty level).

78%: Percentage of the elderly in need of long-term care who receive that care from family members and friends.

34 million: Number of caregivers who provide care to someone age 50 or over.

$113,640: The maximum amount of assets a healthy spouse can retain for the other spouse to be eligible for long-term care benefits provided by Medicaid.

49%: Percentage of nursing home costs covered by Medicaid, 2002.

25%: Percentage of nursing home costs paid out of pocket, 2002.

7.5%: Percentage of nursing home costs covered by private insurance, 2002.

79: Average age upon admittance to a nursing home.

40%: The percentage of individuals who reach age 65 who will enter a nursing home during their lifetimes.

892 days (2.44 years): Average length of stay for current nursing-home residents, 1999.

272 days (8.94 months): Average length of stay for discharged nursing-home residents, 1999.

38%: Percentage of nursing home patients who will eventually be discharged to go home or to another setting.

10%: The percentage of people who enter a nursing home who will stay there five or more years.

65%: The percentage of people who entered a nursing home who died within one year of admission.

Five months: The typical length of nursing-home stay for patients who eventually died in the nursing home.

25%: The percentage of deaths in the U.S. that occurred in nursing homes, 2010.

40%: The expected percentage of deaths in the U.S. occurring in nursing homes by 2020.

68%: The probability that an individual over age 65 will become cognitively impaired or unable to complete at least two "activities of daily living"--including dressing, bathing, or eating--over his or her lifetime.

42%: The percentage of individuals in nursing homes who are experiencing some form of dementia.

33%: The percentage of individuals in nursing homes who are suffering from some form of depression.

71%: Percentage of patients with advanced dementia who died within six months of admission to a nursing home.

$73,000: Median annual rate, nursing-home care in U.S.

3.63%: Increase in median annual nursing-home costs since 2011.

4.5%: Annualized increase in median annual nursing home costs, 2008-2012.

$162,425: Annual cost of nursing home care, Manhattan, N.Y.

$60,773: Annual cost of nursing home care, Des Moines, Iowa.

$86,140: Annual cost of nursing home care, Tampa, Fla.

$41,000: Average annual base rate for residence in assisted living facility, 2012.

$20: Average hourly rate for licensed, non-Medicare-certified home health aide.

7 to 9 million: Estimated number of U.S. residents who had private long-term care insurance, 2010.

59: Age of typical purchaser of long-term care insurance, 2010.

79%: Percentage of long-term care insurance purchasers with more than $100,000 in liquid assets.

44%: Percentage of population age 50 or older with more than $100,000 in liquid assets.

$1,831: Average annual premium for long-term care policy purchased by person age 55 or younger, at coverage start date. (Policy provides a daily benefit of $150, four to five years of coverage in home and institutional settings with a 90-day waiting period, and 5% automatic compound inflation protection.)

$3,421: Average annual premium for same policy purchased by an individual age 70-74.

9%: Percentage of long-term care insurance purchasers who let their policies lapse within the first year of purchase.

Morningstar Report

What You Need to Know About Long-Term Care
Forget gas prices, college costs, and cable bills. If you want an example of skyrocketing inflation, look no further than long-term care insurance premiums, which have jumped between 6% and 17% during the past year alone, reports Morningstar's Christine Benz. As insurance companies feel the pinch, existing policyholders have been confronted with the choice of swallowing higher premiums or accepting benefit cutbacks.

Given the current environment, many investors have decided to self-insure or depend on Medicare and Medicaid, which both have their own complications (Medicare only covers long-term care needs under a limited set of circumstances, and qualifying for Medicaid can be devilishly complicated).

In a series of popular articles in August, Morningstar's Chr istine Benz described why Medicare isn't much of a safety net for true long-term "custodial" care, explained what Medicaid will and won't provide, and discussed some practical takeaways. She also offered more than three dozen must-know statistics about long-term care to help investors frame their thinking, and she concluded the series with a set of top tips for self-insurers.

In the next post I will try to paste in the specifics from the Benz articles.

Michael

Sex in the nursing home

Had some trouble pasting this to the blog, so my apologies if this has been confusing.  I have deleted the earlier posts made in error.  I think.

So, SEX.  This article from MSNBC indicates that in Australia, at least, sex may not be allowed in the nursing home.  So, part of our planning must be to:

1.  Make sure that the nursing home we are likely to end up in (remember, we childless must make this decision ourselves at a time when we can still make decisions) will allow us to either a) stay together, or b) sneak into eachother's rooms when, you know, its time to, well, you know.

2.  Retain possession of a car with a wheel-chair accessible back seat.

3.  Give up on SEX.  Yeh, right, like THAT is gonna happen.

#2 could be problematic, #3 just ain't gonna happen, so lets concentrate on the first option.

By Arthur Caplan, Ph.D.

When it comes to the elderly, almost no one wants to talk about sex. This is especially true when nursing home and residential care are involved.

According to new report by a group in Australia in the Journal of Medical Ethics, the idea that adults should be able to engage in sexual relationships whenever, and with whomever, they choose becomes very complicated for residents in most nursing homes. For residents with dementia, romantic intimacy is especially discouraged.

Many older people, including those with early stage dementia, enjoy sex while living at home with their spouses. But this ends once they move into a nursing home, even for long-term couples, note the researchers from the Australian Centre for Evidence-Based Aged Care. Married or not, sex ends at the nursing home door.

Nursing homes are simply not set up to permit romance. Privacy is at a premium and few room doors lock. Most rooms are double-occupancy with single beds. And nursing home staff don’t typically encourage romance and sex. It's one less thing for nursing home owners and administrators to worry about.

We're so prudish about the elderly and intimate relationships that we don’t even broach the topic when a loved one is heading to a home. We consider freedom and autonomy when debating who will have the right to pull the feeding tube or turn off the dialysis machine if Mom or Dad can't communicate, but we do nothing to ensure their right to enjoy themselves in an area of life that matters a great deal to them.

Sex may not be for every nursing home resident, but it is surely for some. That's autonomy worth talking about.

A nursing home ought be at least as tolerant as a prison. Some prisons permit conjugal visits. Shouldn’t we expect the same of nursing homes? If you care about your parents' and grandparents' dignity, sex ought to be a topic of conversation regarding the nursing home if that's where they're headed or where they now live.

Bioethicist Art Caplan is the head of the Division of Medical Ethics, NYU Langone Medical Center.