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Aging

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It is disconcerting when the medical community reverses course. They seem to do that every decade or so, as with the purported value of vitamin C, estrogen and so forth. The latest about face, in case you haven’t yet heard, is on the matter of taking baby aspirin. For years we have been urged to take a baby aspirin each day to ward off all sorts of ills: heart attacks, strokes, dementia, colorectal cancers and who knows what else. Those tiny pills that can dissolve in seconds against the roof of one’s mouth, or be popped into it, seemed capable of miracles.

Now, with a shot heard truly around the world, an Australian research team at Monash University in Melbourne concluded that not only may aspirin not help, it may in some cases actually harm. The results of their study, which included more than 19,000 people over 4.7 years, were published in three articles this past Sunday in the prestigious New England Journal of Medicine and summarized by The New York Times on Monday, and by just about all other major media.

The study included whites 70 and older, and blacks and Hispanics 65 and older. Each took 100 milligrams — slightly more than the 81 milligrams of a baby aspirin — or a placebo each day. While doing so did not lower their risks of diseases, it did increase “the risk of significant bleeding in the digestive tract, brain or other sites that required transfusions or admission to the hospital,” according to The Times.

So what does all that mean, especially for those already at risk for the conditions aspirin was supposed to protect against?

I am going to quote from The Times very carefully here because this can get confusing due to mixed messages. “Although there is good evidence that aspirin can help people who have already had heart attacks or strokes, or who have a high risk that they will occur, the drug’s value is actually not so clear for people with less risk, especially older ones,” wrote reporter Denise Grady.

So can aspirin prevent cardiovascular events in people with diabetes, for example, or is the benefit outweighed by the risk of major bleeding? Does dose matter in that heavier people might require more aspirin to be prophylactive?

Here’s what the study tells us: Healthy older people should not begin taking aspirin. This will no doubt disappoint Bayer, St. Joseph and others who manufacture the drug. But those who have already been using it regularly should not quit based on these findings, according to Dr. John McNeil, leader of the Australian study. Rather they should talk with their doctors first because the new findings do not apply to those who have already had heart attacks or strokes, which involve blood clots. Aspirin is known to inhibit clotting.

The name of this study is Aspree and it was funded by the National Institute on Aging, along with the National Cancer Institute, Monash University and the Australian government. Bayer supplied the aspirin and placebos but had no other role, according to The Times.

The study focuses on preventive medicine, especially how to keep older people healthy longer. It included 16,703 people from Australia and 2,411 from the United States, starting in 2010. Serious bleeding occurred in 3.8 percent of the aspirin group as opposed to 2.7 percent in the placebo group.

McNeil does suggest the possibility that aspirin’s protective effect against colorectal cancers might still exist but not show up for a longer time span than the study. The Times article does go on to say that the good doctor, who is 71 and specializes in epidemiology and preventive medicine, does not himself take aspirin.

Don’t know what to do? As they say in the commercials, consult your doctor.

If parts of the body could talk, I wonder what they’d say. To that end, I imagined the following dialogue among mostly facial features.

Teeth: Hey, look at me. Something’s changed. You’re going to like it.

Ears: What? You’re talking again? Seriously. Can’t you give it a rest, just for a few moments? Here’s a news flash: You don’t have to eat crunchy food all the time. How about eating something soft once in a while?

Teeth: Crunchy food tastes good.

Tongue: Yes, but the ears have a point. That crunchy stuff scratches me.

Eyes: Keep it down. I’m surfing the net and you’re distracting me.

Nose: Oh, how wonderful. You get to look for stuff all day long, while I’m sitting here waiting for Eileen to share perfume that smells like flowers.

Ears: So, you like Eileen?

Nose: No, but she smells a lot better than we do. Our armpits leave something to be desired at the end of the day. It’s amazing we’re still married.

Armpit: You wouldn’t smell so great either if you got damp every time the stress level started to rise. Besides, with all that running, nose, I’d think you’d be in better shape.

Nose: Is that supposed to be funny?

Armpit: I’m sorry. I know it’s not your fault. Maybe my stress would be lower if the eyes didn’t spend so much time reading about politics.

Teeth: Wait, guys. Come on, I want to tell you something. You’re going to like it.

Ears: Oh, please. Are you going to tell us that you have a few more thoughts you’d like to share about a way to smile so we look better in selfies? Forget it. Haven’t you heard? Your daughter said you’re incapable of taking a good selfie. She’s probably right. Selfie’s were made for people much younger than we are. They’re a tool to even out the generational power struggle.

Cheeks: We’re as young as we feel, right?

Eyes: Have you looked in the mirror lately? Cheeks, you’re showing our age.

Cheeks: Wait, what’s wrong with me?

Eyes: Nothing’s wrong. It’s just that gravity seems to have caught up with you.

Chin: Gravity, that’s funny.

Eyes: You haven’t looked in the mirror either, have you chin?

Chin: Why?

Eyes: Are you trying to clone yourself?

Nose: Ignore them, cheeks and chin. They’re just jealous.

Eyes: Jealous? What? Let’s just say that the new hairs coming out of you, my little nose friend, aren’t winning admirers.

Nose: Hairs? Where?

Ears: Can we keep it down? I’m trying to enjoy the few moments of silence before the phone rings or
someone else has to share thoughts about a better way to do something.

Eyes: We noticed the extra hairs growing on you, too, ears.

Ears: You’re in a bad mood today, eyes. What’s wrong?

Eyes: Nothing.

Teeth: No, you can tell us.

Eyes: I need to wear close glasses for the computer and distance glasses for driving. I hate having two pairs and it takes me a minute to adjust.

Nose: Tell me about it. The computer glasses are pinching me.

Ears: Yeah, and they’re irritating me, too.

Teeth: Come on. I have something to say.

Ears; Of course you do. That’s all you do. Blah, blah, blah. Would it hurt you to listen?

Teeth: I am part of the mouth, you know. That’s what I do.

Ears: Yes, but silence can be good for all of us, you know?

Eyes: OK, tell us this important news that you’re so eager to share.

Teeth: After all these years, my teeth are straight. See? My smile isn’t crooked anymore.

Eyes: Let me see.

Teeth: Aah.

Eyes: Hmm, they are straighter. What do you know? Now, what can you do about your breath?

Aging isn’t for sissies. We’ve all heard that line before and it also applies to our pets, our cats and dogs, our horses and so forth. Teddy is our only pet, a golden retriever with a square head, a pug nose, expressive brown eyes and an affable disposition. He has lived with us since he was 8 weeks, and in June he will turn 12.

It’s hard for us to see him getting old. He is totally deaf now and only knows we are there when we touch him. Then he will be startled as he whips his head around to see us and slowly wags his tail as if to say, “Oh, I know you, I’m safe with you.” He has serious cataracts that interfere with his vision, and he is beginning to bump into the corners of furniture. He’s gone white around his muzzle, although the changeover from light blond isn’t so dramatic. And while he still can find his way back to the front door after he’s gone out, he occasionally wanders aimlessly inside the house. Sometimes he just sits and stares at a wall. Yet most of the time, he is his usual self, putting his head in each of our laps in turn as we sit in the living room and nuzzling us with love.

Worst of all, for no reason we can discern, he will begin a chorus of howling. It’s a curious chain of sounds, starting at a high pitch and dropping down until it is wolverine, coming from deep in his throat. He throws his head back when he howls, much like the wolves I saw in the Oregon Zoo in Portland. Maybe it’s the equivalent of a primordial scream, or maybe he is communing with his ancestors, telling them he is on his way. It brings us to tears.

My sons tell me we should have cataract surgery for him on one eye to enable him at least to see better.

“You’d be howling, too, if you couldn’t see or hear,” they argue. Of course they have a point. But I am afraid, afraid of what Teddy’s reaction to the anesthetic might be, afraid to send him to a place of unfamiliarity, afraid to subject him to invasive procedure.

To further complicate the picture, he has had a seizure. We saw the whole thing. It happened only 10 minutes after the last of our dinner company had left a few weeks ago. He was laying down on his side in his familiar station near the front door when suddenly his legs started flailing at the air, he began panting and saliva started to bubble from his mouth. All we could do was look on in horror for the short time that it lasted. When it was over he became uncharacteristically aggressive for a couple of minutes. Then his breathing slowly returned to normal, and he started walking from room to room. After perhaps 15 more minutes, while we watched with concern, he sauntered over to his food bowl as if nothing had happened and began eating all his dinner, finishing up with a noisy slug of water. Finally he spun around, plopped down and looked at us as if to say, “Why are you following me?”

We called the vet, who seemed much more sanguine than we were and assured us that this sometimes happens to pets, although it had not happened to any of our preceding three dogs. She put him on meds to prevent another seizure.

What followed was a trial-and-error course of medication that alternately left Teddy so wobbly that he could barely step off the porch and caused him to sleep constantly, or wound him up so that he howled intermittently through the night, needing reassurance each time that we were there. It was like having a newborn baby in the house demanding multiple feedings.

We’ve finally gotten the right medicines to the right level and life is almost back to normal, but the questions remain: What to do next, and when to do it?

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By Nancy Burner, ESQ.

For most of us, if a time comes when we need assistance, the preferred option would be to remain at home and receive whatever care services we needed in our familiar setting surrounded by family. For many, the Community-Based Long-Term Care Program, commonly referred to as Community Medicaid, makes that an affordable and therefore viable option.

Oftentimes we meet with families who are under the impression that they will not qualify for these services through the Medicaid program due to their income and assets. In most cases, that is not the case. Although an applicant for Community Medicaid must meet the necessary income and assets levels, oftentimes with planning we are able to assist in making an individual eligible with little wait.

An individual who is applying for homecare Medicaid may have no more than $14,850 in nonretirement liquid assets. Retirement assets will not be counted as a resource as long as the applicant is receiving monthly distributions from the account. An irrevocable prepaid burial fund is also permitted as an exempt resource. The primary residence is an exempt asset during the lifetime of the Medicaid recipient. However, when the applicant owns a home, it is advisable to consider additional estate planning to ensure that the home will be protected once the Medicaid recipient passes away. 

Although the home is considered an exempt resource as long as the Medicaid recipient is living in it, once the applicant passes, Medicaid can assert a lien on the home if it passes through the probate estate. One way to avoid this is to ensure that at the time of the death of the applicant no assets pass through the probate estate; this can be achieved by transferring the home to a trust. Once this is done, the home will pass to the intended beneficiaries without a probate proceeding and without an opportunity for Medicaid to seek recovery against the home. 

With respect to income, an applicant for Medicaid is permitted to keep $825 per month in income plus a $20 disregard. However, where the applicant has income that exceeds that $845 threshold, a Pooled Income Trust can be established to preserve the applicant’s excess income and direct it to a fund where it can be used to pay his or her household bills.  It is important to note that there is no “look back” for Community Medicaid. This means that for most people, with minimal planning, both the income and asset requirements can be met with a minimal waiting period allowing families to mitigate the cost of caring for their loved ones at home, in many cases making aging in place an option.   

Individuals looking for coverage for the cost of a home health aide must be able to show that they require assistance with their activities of daily living. Some examples of activities of daily living include dressing, bathing, toileting, ambulating and feeding.

Community Medicaid will not provide care services where the only need is supervisory; therefore, it is important to establish an assistive need with the tasks listed above. Once this need is established, the amount of hours awarded will depend upon the frequency with which assistance with the tasks are necessary. 

For example, an individual who only needs help dressing and bathing may receive minimal coverage during the scheduled times, maybe two hours in the morning and two hours in the evening. Contrast that with an individual who requires assistance with ambulating and toileting. Because these tasks are considered “unscheduled,” the hours awarded will be maximized.

In fact, where the need is established, the Medicaid program can provide care for up to 24 hours per day, seven days per week. Once approved, the individual may be enrolled in a managed long-term care company. The MLTC may also cover adult day health care programs, transportation to and from nonemergency medical appointments and medical supplies such as diapers, pull-ups, chux and durable medical equipment.

The Community-Based Medicaid Program is invaluable for many seniors who wish to age in place but are unable to do so without some level of assistance.

Nancy Burner, Esq. has practiced elder law and estate planning for 25 years.

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