Palliative Care Is MoreCare, Not Less

by Rachel Selby-Penczak, MD

Educational Objectives

1. Discuss the origins of hospiceand palliative care.2. Compare and contrast Curative,Palliative, and Hospice Models ofCare.3. Identify when palliative care isappropriate.

Background

Both palliative care and hospiceshare a similar background and pur-pose, making it difficult to discussone without the other.

The word “hospice” derives fromthe same Latin root as “hospitality”and can be traced back to medievaltimes, referring to a place of shelterand rest for weary or ill travelers ona long journey. It was first appliedto specialized care for dyingpatients by Dame Cicely Saunders,a physician who began her workwith the terminally ill in 1948 andwent on to create the first modern

hospice, St Christopher’s Hospice,almost two decades later in a resi-dential suburb of London.

Dr. Saunders introduced this con-cept of care to the United States in1963, during a visit to Yale Univer-sity. Her lecture to medical stu-dents, nurses, social workers, andchaplains about the concept ofholistic hospice care included pho-tos of terminally ill cancer patientsand their families, showing the dra-matic differences before and aftersymptom management. Althoughher lecture served as the launchingpad of a long chain of events thateventually resulted in the develop-ment of hospice care as we know ittoday, the U.S. Congress did notmake the Medicare Hospice Benefitpermanent until 1986.

The word “palliative” derives fromLatin palliare, meaning to “cloak,conceal or alleviate symptomswithout curing,” and can be foundin documents traced back to the late14th century in Elizabethan andIndo-European traditions.

Modern day use of the term pallia-tive care first occurred in 1974, byCanadian surgical oncologist and

Saunders student, Dr. BalfourMount, as a means to help Frenchspeaking Canadians accept the con-cept of holistic care for people withchronic or life limiting diseases,while dispelling the poor reputationand negative connotation of destitu-tion that had become affiliated withhospice institutions in France.

Books including On Death andDying by Dr. Elisabeth Kubler-Rosspublished in 1969, demonstrationprojects funded by the Robert WoodJohnson and John A Hartford Foun-dations, grants supported by GeorgeSoros’ Open Society Institute, the1997 report from the Institute ofMedicine entitled “ApproachingDeath: Improving Care at End ofLife (M.I. Field and C.K. Cassel,editors), and consumer awarenessefforts through Last Acts, and theBill Moyer’s Series “On Our OwnTerms” (2000) have all playedimportant roles in bringing to thepublic the concept of “total care”for any patient, adult or child, diag-nosed with life-limiting illness, aswell as those who are dying, and inmany cases, influencing policiesboth in the U.S. and elsewherearound the world.

Inside This Issue:

VCoA Editorial, 6DARS Editorial, 8ARDRAF Final Reports, 10

MEOC Receives N4A Award, 13Medicare Advantage Plans, 14Chocolate and Health, 16

10 Ways to Love Your Brain, 16GTE Grants Available, 17Calendar of Events, 18

Case Study

Volume 31 Number 4 Fall 2016

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As of 2006, Hospice and PalliativeMedicine became a recognized sub-specialty by both the AmericanBoard of Medical Specialties(ABMS) and the AccreditationCouncil for Graduate Medical Edu-cation; since 2008, physicians whoqualify have been able to takeexaminations that certify theirexpertise in this important area ofmedicine.

Curative versus Palliative Care

Healthcare in the U.S. has a strongtendency to focus on cure, which,while important, can also lead topatient and family suffering, causepatient and family goals to be over-looked, and quality of life to bemistakenly considered as lessimportant.

Curative care tends to focus oncure. In the process of focusing onthe disease itself, the goal oftenbecomes eradicating or slowingprogression of disease, duringwhich the patient may be viewed asa collection of parts or organ sys-tems, with the body often differenti-ated from the mind. It places highvalues on measurable data, such aslabs and radiology reports, and ingeneral views death as the ultimatefailure.

On the other hand, palliative carefocuses on the relief of suffering forthe patient and his or her family. Itlooks to treat symptoms, rather thanviewing them as clues to diagnosis.Data may be considered part of thepicture, but it’s the subjective, oftendifficult to quantify, informationprovided by the patient and thefamily that’s given the highestvalue. Palliative care looks to con-trol symptoms and relieve suffer-

ing, whether or not the underlyingdisease can be eradicated orslowed, and views the patient as awhole, basing treatments on thevalues, beliefs, and concerns of thepatient and the family. Success isviewed as enabling the patient andthe family to live as fully and com-fortably as possible until death,whenever it may come.

Palliative Care Defined

The World Health Organization formally defined the term palliativecare in 1989, and published a re-vised definition in 2002:

“Palliative care is an approach thatimproves the quality of life ofpatients and their families facingthe problems associated with lifethreatening illness, through the pre-vention and relief of suffering bymeans of early identification andimpeccable assessment and treat-ment of pain and other problems,physical, psychosocial and spiritu-al.”

“Palliative care: provides relieffrom pain and other distressingsymptoms; affirms life and regardsdying as a normal process; intendsneither to hasten or postponedeath; integrates the psychologicaland spiritual aspects of patientcare; offers a support system tohelp patients live as actively as pos-sible until death; offers a supportsystem to help the family cope dur-ing the patient’s illness and in theirown bereavement; uses a teamapproach to address the needs ofpatients and their families, includ-ing bereavement counselling, ifindicated; will enhance quality oflife, and may also positively influ-ence the course of illness; and is

applicable early in the course of ill-ness, in conjunction with othertherapies that are intended to pro-long life, such as chemo-therapy orradiation therapy, and includesthose investigations needed to bet-ter understand and manage dis-tressing clinical complications.”

Medicare has also recognized pal-liative care as important, noting thatit should be part of overall caremanagement based on need, notprognosis.

Through education, the public hasbegun to view palliative care forwhat it really is: a team-basedapproach to care that will improvequality of life, provide an extralayer of support, and can be givento any person, at any age, and atany stage of the serious illnessalongside curative treatments. Palliative care can be provided inany setting, including home, hospi-tals, clinics, and nursing facilitiesand applies to any number ofchronic and life limiting illnesses,including, but not limited to: can-cer, cardiac disease and heart fail-ure, kidney failure, cirrhosis of theliver, lung disease, multiple sclero-sis, Alzheimer’s and other demen-tias, Parkinson’s disease, HIV, anddrug-resistant tuberculosis. Whenfirst diagnosed with a chronic ill-ness, the focus may be mostly cura-tive, but as time goes on the amountof curative and palliative interven-tions may fluctuate and graduallyshift towards a progressively morepalliative approach.

One of the most well-known ran-domized controlled studies of thebenefits of palliative care is byTemel and colleagues (2010). Itdemonstrated that those patients

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with newly diagnosed metastaticnon-small cell lung cancer whoreceived early palliative care along-side standard cancer care hadimproved quality of life, reduceddepression, and longer survival,compared to those patients receiv-ing standard care alone, eventhough the former received lessaggressive interventions.

Although hospice and palliativecare share similar goals and focus,they are not the same, and despitestudies to the contrary, patients arenot the only ones to associate, mis-takenly, the term palliative withdeath or hospice. Studies (Fadul,2009; Dalal, 2011) have shown thatclinical providers and oncologistswere more likely to embrace theuse of and consult palliative careservices if the name were changedfrom Palliative Care to SupportiveCare.

It is important to mention that whileMedicare has a distinct paymentsystem for hospice services, cur-rently there is no equivalent pay-ment system to easily facilitate pal-liative services delivered in a com-plete and coordinated interdiscipli-nary package.

Hospice Defined

Hospice is a group of services andthe largest provider of palliativecare in the country. It is a compre-hensive and holistic approach totreatment that recognizes that theimpending death of an individualwarrants a change in focus fromcurative to palliative care for reliefof pain and symptom management,providing compassionate patientand family-centered care for thosewho are terminally ill.

The goal is to help terminally illindividuals continue life with mini-mal disruption to normal activities,while remaining primarily in thehome.

Hospice is an interdisciplinaryapproach to deliver medical, nurs-ing, social, psychological, emotion-al, and spiritual services with thegoal of making the individual asphysically and emotionally com-fortable as possible; the expectationis that the care plan will shift overtime to meet the changing needs ofthe patient and the family, whileviewing both the patient and thefamily as a single unit of care.

However, unlike the palliativemodel, in the United States,Medicare has determined that a per-son is only eligible for hospice if inthe terminal phase of the disease,with a life expectancy of sixmonths or less, and if willing togive up curative treatments. Thatbeing said, some treatments such asradiation, chemotherapy and dobut-amine may still be allowed by somehospice agencies if they are specifi-cally for comfort and symptommanagement and are consistentwith the goals of the patient.

Hospice is considered a skilled ser-vice, and most often occurs wherethe patient lives; however, unlikewith Medicare Home Health Ser-vices, the patient does not have tobe homebound.

The Medicare hospice benefit doesnot end at the patient’s death andincludes bereavement services tothe family for up to 13 months afterthe patient dies.

Case Study #1

Joan is a 48-year-old single motherof three daughters ages 17 to 20years old. She works as a bookkeeper and volunteers at a localmuseum. She presented to the ERwith abdominal pain, nausea, andconstipation. She has a history ofovarian cancer diagnosed two yearsearlier which was treated withsurgery and chemotherapy resultingin successful resolution of the pri-mary tumor. She is started on opi-oids for pain, anti-emetics for nau-sea, and admitted to the palliativecare unit for further symptom man-agement. An aggressive bowel regi-men results in relief of constipation.CT scans of her abdomen andpelvis reveal new tumor recurrence.Oncology is consulted, and whileshe is no longer considered a surgi-cal candidate, she may be a candi-date for further palliativechemotherapy as an outpatient,once her acute symptoms resolveand if her functional status remainsstable.

Despite being in pain, each morn-ing she greets the staff with a smile,and before she is willing to answerquestions about her own symptoms,she insists on expressing her appre-ciation of the care she is receiving,and her hope that the members ofthe medical team are doing well.

Although her nausea improves, herpain remains poorly controlled. Sheis seen by the palliative socialworker, chaplain, and psychologist.

Customary measures for pain con-trol, including escalating doses ofopioids, opioid rotation, and epigas-tric nerve block performed by inter-ventional radiology, have little

impact on her abdominal pain.Throughout the hospitalization,Joan’s code status has been FullCode, meaning that should herheart stop beating or should she beunable to breathe on her own, shewould receive CPR, be intubated,and placed on a ventilator if med-ically indicated. A discussion aboutthe risks and benefits of potentialatypical pain medications led totalking about code status, and thenormally calm Joan became, stating“I don’t want to talk about that. Justgo get the medication.”

With Joan’s permission, her daugh-ters are invited to a family meetingduring which the palliative carenurse and physicians work togetherwith Joan to address goals of care.Upon listening to Joan discuss herclear understanding of her medicalproblems, hearing her goals toremain independent and pursue pal-liative chemotherapy in hopes thatit will enable her to attend herdaughter’s high school graduation,and having the opportunity to seeJoan interact with her daughters, itbecomes obvious that althoughJoan has physical reasons for symp-toms, her uncontrolled pain may, inlarge part, be due to existentialsources of suffering.

Dr. Rose kneels down at beside,looks Joan in the eyes and asks ifshe can share some thoughts thatmight be upsetting. Joan agrees. Dr.Rose expresses her admiration forJoan’s strength and grace, inform-ing her that as a mother of threeherself, Dr. Rose doesn’t know ifshe would demonstrate the samevirtues in a similar circumstance.She explains her suspicion that Joanmay be avoiding discussions aboutcertain topics such as code status in

an effort to protect her daughtersand prevent them from mistakenlybelieving that she has given up. Sheinforms Joan that, given heradvanced cancer for which she isnot a surgical candidate, she is alsonot a good candidate for cardiopul-monary resuscitation; it would beunlikely to work, would not changethe underlying cancer, would add toburden and suffering at end of life,and would bring her further awayfrom her stated goals. Dr. Roseadded that, by not specificallyexpressing her wishes to her daugh-ters now, there may be increasedsuffering for her daughters later, ifthey had to make clinical decisionsfor their mother if she becameunable to make decisions for her-self. Joan thanks Dr. Rose for hercandor and calmly tells her daugh-ters that should her heart stop orend of life draw near, she would notwant to receive CPR or be placedon artificial means of life supportbut rather would want to be keptcomfortable and die with dignity.After responding to the daughters’questions, the palliative team givesthe family private time alone.

The next morning, Joan appearsbrighter and reports much less pain.Over the next few days, her opioidregimen is gradually reduced, sheengages in more open discussionswith the palliative interdisciplinaryteam, and is seen by physical andoccupational therapy. She is dis-charged home on much lower dosesof opioids, with improved pain con-trol, and plans to follow up in theoutpatient Palliative Care Clinic forcontinued symptom management,and with outpatient oncology forpalliative chemotherapy.

Case Study #2

Michael is a 58-year-old father ofthree grown children. He has strongfamily and social networks, andreligion is an important part of hislife. A mechanic, he was diagnosedwith colon cancer in February2009. He underwent surgicalremoval of part of his colon andreceived chemotherapy that wascompleted in September 2009, afterwhich he was feeling good and ableto return to work. Almost a yearlater, he was found to have regionalrecurrence of his colon cancer.Extensive surgery resulted in blad-der and prostate removal, and acolostomy. Despite another sixmonths of chemotherapy, he wasdiagnosed with a second localrecurrence; the regimen was dis-continued, as it interfered with theanticoagulant he was taking fortreatment of blood clots. Hereceived pelvic radiation which wascompleted in May 2012.

In July 2012 he developed abdomi-nal pain and vomiting due to smallbowel obstruction for which he washospitalized twice at a local hospi-tal and managed medically withbowel rest and IV hydration. Whenhis symptoms recurred a third time,he presented to a tertiary medicalcenter for a second opinion and washospitalized once again. His prima-ry oncologist, Dr. Turner, was con-tacted by the inpatient medical teamand she informed them that, despiteaggressive treatment, Michael’scancer had progressed to the pointthat recurrent partial small bowelobstructions would likely continue.She was concerned about Michael,and stated that at their last visit heand his wife Sheila were having ahard time accepting the information

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given to them and were understand-ably tearful when they left. She rec-ommended focusing on symptomcontrol as the best option. At thetime of his discharge in earlyAugust, his symptoms had resolvedand he was tolerating a normal diet.

In late August, he had an outpatientappointment with Dr. Smith, anoncologist at the tertiary medicalcenter, for a second opinion. Dr.Smith discussed possible treatmentoptions, including the risks, bene-fits, and possible toxicity from fur-ther chemotherapy, pointing outthat any treatment at this pointwould be palliative, with possibleextension of life, but without cure.Michael and his wife decided topursue this route.

Chemotherapy was delayed byinsurance issues, and over the nexttwo months he was hospitalizedthree more times. CT scans of hisabdomen and pelvis were comparedto those done a month earlier andrevealed new metastatic disease tohis lungs and soft tissue. Laparo-scopic exploratory surgery wasoffered which Michael initiallydeclined in favor of more conserva-tive management with total periph-eral nutrition (TPN) and symptommedications.

Michael was seen by the PalliativeCare Chaplain and expressed con-cerns about his body image, shouldhe proceed with further surgery.The Palliative Care Psychologistalso met with him, providing edu-cation and teaching him breathingand other relaxation techniques, asa means to help manage stress andanxiety related to his health prob-lems and inability to work for thepast two years.

In late October, Michael was takento the operating room for laparo-scopic surgery with extensiveremoval of adhesions and removalof his distal small bowel. His postop course was complicated bydelayed return of bowel functionand fever related to intraabdominalabscesses for which he was startedon broad spectrum antibiotics.

He was transferred to the palliativecare unit for further symptom man-agement. Despite aggressive med-ical treatment and improved symp-tom management with help of thePalliative Care Interdisciplinaryteam, it became clear that he wouldno longer be a candidate for pallia-tive chemotherapy and that the riskof continuing TPN outweighed thebenefits, given the persistent infec-tion and sepsis. With his poor prog-nosis and life expectancy of two tofour weeks, Michael chose to returnhome to focus on quality of lifewith his family.

He was enrolled in home hospice inlate December 2012. Over the nextnine months, the hospice teamhelped manage Michael’s symp-toms at home. Despite continuedweight loss and periodic low gradefevers, he was able to enjoy timewith his family, go fishing with hiswife, and avoid further hospitaliza-tion. He died peacefully at home inearly September 2013.

Conclusion

The concept of both palliative andhospice care has been around forcenturies. While scientific and tech-nological advancements have pro-vided the means for cure and pro-longation of life to those withchronic and life limiting illness,

such measures may also contributeto increased symptom burden, addto suffering, and detract from quali-ty of life. The biggest mistakepatients, families, and cliniciansmake is believing that one mustchoose between cure and comfort,waiting too long to ask for a pallia-tive care referral. Regardless of dis-ease stage, it is never wrong to treatsymptoms and make sure that allmedical interventions pursued areconsistent with patient and familygoals. Although the cases discussedhere highlight two patients withcancer, palliative care can andshould be provided for all patients,at any stage of any chronic or lifelimiting illness or disease, as stud-ies have shown that doing so mayresult in improved length and quali-ty of life, better patient and familysatisfaction, and lower costs at endof life.

Study Questions

1. What are the differences betweencurative and palliative care?2. When should one receive hospiceinstead of palliative care?3. Which types of symptoms can beaddressed by palliative care andwho are the typical members of apalliative care team?

References

Clark, D. (2007). From margins tocentre, a review of the history ofpalliative care in cancer. The LancetOncology, 8, 430-438.

Connor, S. (2007-2008). Develop-ment of hospice and palliative carein the United States. Omega, 56(1),88-99. Available at: www.researchgate.net/profile/Stephen_Connor6/publication/ 5797129_

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Development_of_Hospiceand_ Palliative_Care_in_the_United_States/links/55e0c5b908ae2fac 471cb77d.pdf.

Dalal, S. (2011). Associationbetween a name change from pal-liative to supportive care and thetiming of patient referrals at a com-prehensive cancer center. Oncolo-gist, 16(1), 105–111. Available at:www.ncbi.nlm.nih.gov/pmc/articles/PMC3228056/

Fadul, N. (2009). Supportive versuspalliative care: What's in a name? Asurvey of medical oncologists andmidlevel providers at a comprehen-sive cancer center. Cancer, 115(9),2013-21. Available at: onlinelibrary.wiley.com/doi/10.1002/cncr.24206/full

Loscalzo, M. (2008) Palliative care:An historical perspective. Hematol-ogy, 8(1), 465. Available at: asheducationbook.hematologylibrary.org/content/2008/1/465.full

Morgan, D. (2009). Caring fordying children: Assessing the needsof the pediatric palliative carenurse. Pediatric Nursing, 35(2), 86-91. Available at: www.medscape.com/viewarticle/707801_2

Palliative Care South Australia.History of palliative care. Availableat: www.pallcare.asn.au/Palliative-CareSA/History-of-palliative-care

Temel, J., Greer, J., Muzikansky,A., Gallagher, E., Admane, S., Jack-son, V., Dahlin, C., Blinderman, C.,Jacobsen, J., Pirl, W., Billings, J. &Lynch, T. (2010). Early palliativecare for patients with non-small-cell lung cancer. New EnglandJournal of Medicine, 363(8), 733-

742. Available at:www.nejm.org/doi/pdf/10.1056/NEJMoa1000678

WHO definition of Palliative Care. Available at: www.who.int/cancer/palliative/definition/en

Worldwide Palliative Care Allianceand World Health Organization(January 2014). Global Atlas ofPalliative Care at the End of Life.Available at: www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf

About the Author

Rachel Selby-Penczak, MD, is anAssistant Professorof Medicine in theDivision of Geri-atrics at Virginia

Commonwealth University (VCU)Health Systems in Richmond, VA.She has been providing medicalcare to patients in their homes andin nursing homes since 1999. Forthe past 5 years she been part of thepalliative care interdisciplinaryteam at VCU providing consultativeservices and care to patients andfamilies throughout the hospital.Her e-mail is: rachel.selby-penczak@ vcuhealth.org.

From theDirector, Virginia Center on Aging

Edward F. Ansello, Ph.D.

Fix and Fit to Age in Place

Most of us want to grow old in ourown homes, to age in place.

Social determinants of aging. Theseare features in someone’s life, likeneighborhoods, existing resources,education, occupation and income,which shape how an individual (orgroup) experiences growing older.These social and environmentalfactors can help create positive,helpful conditions or negative,unhelpful conditions.

We’ve written about how sidewalkcurb cuts, accessible entryways,and walkability can facilitate fullerparticipation in work and communi-ty life for persons with physical andintellectual disabilities; there’s alsothe role that removing policy barri-ers can play in enriching and “nor-malizing” the lives of individualswith disabilities.

Now come findings that simpleimprovements in housing, coupledwith modest person-centered sup-ports, can improve the health anddaily lives of poor older adults withlimitations, enabling them to age inplace.

An interdisciplinary team of a reg-istered nurse, an occupational thera-pist, and a handyman made minorimprovements in the houses of poorelders and introduced simple assis-tive devices, each time focusing onthe specific situation of the individ-

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ual. Five months later, participatingolder adults had improved theirability to take care of themselvessubstantially, reducing by almosthalf the number of their impair-ments in Activities of Daily Living,and reducing their levels of depres-sion.

Here’s how it worked. Sarah Szan-ton, a nurse practitioner and associ-ate professor of nursing at JohnsHopkins University, led a team atHopkins (Sarah Szanton, BruceLeff, Jennifer Wolff, LakenRoberts, & Laura Gitlin) in a pro-ject called CAPABLE (CommunityAging in Place, Advancing BetterLiving for Elders), funded 2012-2015 by the Center for Medicareand Medicaid Innovation, focusedon improving everyday physicalfunctioning. Szanton has writtenelsewhere on the effect of povertyon physical functioning, cognitiveability, and mortality. This project’sfindings are in the September 2016issue of Health Affairs.

The CMS Innovation Center is sup-porting projects to investigate ifhigh-cost users of the health caresystem have problems that can beaddressed cost effectively in waysother than usage of traditionalhealth care processes, like brick-and-mortar medical centers. Diffi-culties with Activities of Daily Liv-ing (feeding oneself, bathing, dress-ing, walking, etc.) and InstrumentalActivities of Daily Living (shop-ping, taking medications, doinglaundry, etc.) strongly predict use ofexpensive chronic care services andinstitutionalization. Yet traditionalhealth care services seldom addressthese.

CAPABLE is one of several inves-

tigations looking into ways toimprove everyday functioning andthereby promote aging in place andreduce long-term care costs. Partici-pants in CAPABLE had to be livingin a house and could not be cogni-tively impaired, and be receivingskilled home health care services orhave been hospitalized four or moretimes in the previous year. All weredually eligible for Medicare andMedicaid. Forty-five percent livedalone.

The CAPABLE interdisciplinaryteam comprised an occupationaltherapist, who made six visits toeach participant; a nurse, who madefour visits; and a handyman, wholabored up to a full day in providinghome repairs, installing assistivedevices, and making home modifi-cations.

Participants worked with the occu-pational therapist (OT) and nurse insemi-structured interviews to iden-tify up to three achievable goalswith each of these two disciplines.The OT observed the participant’scurrent behavior regarding thesegoals and identified barriers toachieving them. For instance, withsafe bathing, barriers might includea slippery tub, muscle weakness,and lack of hand rails.

The OT created a work order forthe handyman prioritized by theparticipant, with each participant’sdwelling having a budget of up to$1300. The handyman then made,within three weeks, all improve-ments needed for participants toovercome the barriers; if neededrepairs exceeded the budget, thehandyman made repairs as weremost feasible. Spending on assis-tive devices and home repairs and

modifications ranged from $72 to$1,398 for each participant. The nurse helped the participantidentify and prioritize up to threegoals related to pain, depression,strength and balance, medicationmanagement, or communicationwith primary care providers.

CAPABLE built in procedures tohelp participants better face subse-quent challenges, employing andtesting problem solving strategiesthat might be useful later on. Thenurse communicated with the pri-mary care provider and the partici-pant’s family members about iden-tified medical issues. In the nextthree visits, “the nurse and partici-pant brainstormed and plannedincremental actions to address eachof the participant’s goals. Forexample, they might decide to tryhaving the participant use the toiletat specified intervals and changingwhen the participant took a diuret-ic, so that he or she was less likelyto have to rush to the bathroom atnight and risk a fall.”

During the final visit, the nursereviewed what the participant hadfound effective and helped him orher to consider how to apply whatwas learned to future challenges.The nurse also wrote to the primarycare provider to summarize the par-ticipant’s goals and how well he orshe had achieved them.

CAPABLE involved 283 partici-pants over a three-year period, with234 providing complete data. Ofthese, 83 percent were women and80 percent were African American.All of them lived at home with orwithout family members.

Results are impressive. At baseline,

participants had difficulty with 3.9of the 8.0 ADLs. At the end of thefive-month CAPABLE program,these difficulties were reducedamong 75 percent of participants.Difficulties in ADLs dropped froman average of 3.9 activities to diffi-culties in 2.0 activities, a 49 percentimprovement in physical function-ing.

Difficulties with instrumental ADLsdecreased in 65 percent of partici-pants. The average decrease in dif-ficulty was from 4.1 activities to2.9 activities. Importantly, multi-variate model analyses showed thatage, race, and symptoms of depres-sion at baseline were not significantpredictors of functional improve-ments. The project itself and its per-son-centered focus seemed to makethe difference.

Depressive symptoms improved in53 percent of the participants.Home hazards decreased from anaverage of 3.3 hazards to 1.4 haz-ards.

Participants benefited equally fromCAPABLE whether or not they hadbeen hospitalized in the previousyear.

The average cost of delivering theprogram was $2,825 per partici-pant. This included all ten clinicianvisits, mileage, care coordination,supervision, home repair and modi-fication (including parts and labor),and assistive devices, as well asoverhead paid to the handymanorganization. This is lower than thecosts previously reported in theCAPABLE pilot project becauseexperience helped to reduce costs.

So the questions are: does the

CAPABLE initiative ultimatelysave tax payer money by reducingmore expensive chronic care andinstitutional costs? Do the findingsreflect the “halo effect” where sim-ply being paid attention to canimprove outcomes? Cost benefitsmay become clearer through appli-cations of CAPABLE in Michiganand Maine. And separately, theCAPABLE team is conducting anon-going NIH-funded randomizedcontrolled study to help find out therole of social interaction. Controlsubjects will participate in seden-tary activities of their choicethrough visits and time equal towhat the CAPABLE participantsreceived but without the focus onstructural improvements and per-son-centered prioritized goals.

If aging in place is the goal, simpletargeted improvements to one’shome and ability to function in itmay be central.

From theCommissioner, Virginia Departmentfor Aging and Rehabilitative Services

Guest Editorial byMarcia C. DuBois

Director, Division for the AgingVirginia Department for Aging

and Rehabilitative Services

Up and Running

The past few weeks have been awhirlwind of activity as I transi-tioned to my new role as director ofVirginia’s Division for the Aging(VDA). During the first week, Ijoined my colleagues at the Homeand Community Based ServicesConference for a week of intensive,informative sessions. Many of thesessions focused on ManagedLong-Term Services and Supports(MLTSS), and the Home and Com-munity Based Services Final Rulewhich requires person-centeredplanning, conflict-free case man-agement, and integrated settings. Itis heartening to see that aging ser-vice professionals in Virginia areworking diligently to respond tothis changing landscape of servicedelivery.

What a great time to join the VDAteam! Virginia is receiving well-deserved recognition for countlessinitiatives like Live Well, LifespanRespite, Care Transitions, DementiaCare, No Wrong Door, livable com-munities planning, and more. Thevision of making Virginia THEstate for innovative aging servicesand exemplary stewardship isalready being realized and I amdelighted to do my part to continue

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Editorials

2016/2017 DARS Meeting Calendar

Commonwealth Council on AgingJanuary 25, April 12, July 12, andSeptember 20, 2017

Alzheimer’s Disease and Related Disorders CommissionDecember 6, 2016March 7, June 6, August 29, andDecember 12, 2017

Public Guardian and Conservator Advisory BoardNovember 17, 2016March 23, June 22, September 14,and November 9, 2017

For more information, call (800) 552-5019 or visit http://vda.virginia.gov/boards.asp.

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this positive trend.

It feels a bit like coming home. Forthe past several years, I have hadthe pleasure of working with theVirginia Division for the Aging(VDA) in various capacities. As amember of the VDA Monitoringteam, I reviewed transportation ser-vices at 13 Area Agencies on Aging(AAAs) and helped to review AAAArea Plans. Learning about agingservices from the experts hashelped me appreciate the impor-tance of what we do.

Several people have mentioned thatthey wondered why I chose to leavethe disability field for aging ser-vices. For me, disability and agingare inextricably linked, so the tran-sition feels seamless. The 2010Census shows that the prevalenceof disability is 35% for ages 65-69.This figure increases to more than70% for ages 80 and over. Most ofus will experience at least one dis-ability in our lifetime, if we are for-tunate enough to have a long life.

The words “aging” and “disability”also share a negative connotationfor some, yet both are just a part ofthe fabric of all of our lives. Cul-ture and attitude make all of the dif-ference in terms of how we viewourselves and our communities. Inthe past, loss of mobility, hearing,or vision would often result in iso-lation for elders. Likewise, youngerpeople with disabilities were alsosegregated and isolated. Now,changing attitudes, better access inthe community, and advances inassistive technology such as screenreaders, communication devices,and even cell phones, make life eas-ier and foster connectedness andengagement.

Living in a barrier-free environmentwith access to services that supportindependence is meaningful forolder Virginians as well as youngerpeople with physical, mental, sen-sory, or developmental disabilities.The recent loss of one of my par-ents to Alzheimer’s disease reallyunderscored the importance ofcommunity based services and sup-ports in a very personal way.Choosing where to live and havingaccess to a menu of supportive ser-vices that are tailored to each indi-vidual and his or her needs, notone-size fits all, improves every-one’s quality of life.

In my previous role promoting Vir-ginia’s Blueprint for Livable Com-munities, I was able to witness andshowcase the collaborative effortsof local grass roots groups com-prised of AAAs, businesses, foun-dations, and community partnersresponding to changing demograph-ics by creating comprehensive agewave plans. Currently, there arenine active age wave plans in theCommonwealth. Several otherlocalities are well on their way.These local partnerships are criticalto ensuring that vintage Virginianshave a multitude of options thatfoster healthy living in the commu-nity.

It was gratifying to see that livablecommunities’ planning and long-term services and supports werefeatured prominently in the 2016Virginia Governor’s Conference onAging (VGCA). Mark your calen-dars for May 22-23, 2017 at theHotel Roanoke. It was a testamentto the conference organizers thatthe 2016 conference sold out early.The 2017 VGCA promises to be

even bigger and better with a con-tinuation of the themes of CultureChange in Long Term Services andSupports; Safety and FinancialSecurity: Older Adults in the NewVirginia Economy; Livable Com-munities: Overcoming Barriers andSharing Strategies; and a new focuson Community Engagement: Sup-porting and Leveraging the Work ofCitizen Advocates.

In recent weeks, I have enjoyed theopportunity to meet with VDA staffand leaders in aging services inorder to gain a deeper understand-ing of the vital aging services thatare provided by the strong networkof aging service providers in Vir-ginia. My listening tour is justbeginning, though. Many of youmay recall our former Deputy Com-missioner, Bob Brink, and his ener-getic, ambitious tour of all of Vir-ginia’s AAAs over the span of just12 months. He set the bar high, butI am pleased to accept the “BrinkChallenge” and visit each of the 25AAAs within a year. Even though Ihave already been to more than halfof them previously, I did not havethe opportunity to receive a fulloverview of each one. As they say,“If you have seen one AAA, you’veseen one AAA”. Travelingthroughout the Commonwealth toall 25 is no chore, though. In fact, Iam eager to spend more time learn-ing about their unique, local initia-tives and exemplary programswhile enjoying Virginia’s scenicviews.

Editorials

10

COMMONWEALTH OF VIRGINIA

Alzheimer’s and Related Diseases Research Award Fund

2015-2016 Final Project Report Summaries

The Alzheimer's and Related Diseases Research Award Fund (ARDRAF) was established by the Virginia GeneralAssembly in 1982 t and is administered by the Virginia Center on Aging at Virginia Commonwealth University.The awards this year were enhanced by a $25,000 donation from Mrs. Russell Sullivan of Fredericksburg, inmemory of her husband who died of dementia. Sullivan awards are indicated by an asterisk (*). Summaries ofthe final project reports submitted by investigators funded during the 2015-2016 round of competition are givenbelow. To receive the full reports, please contact the investigators or the ARDRAF administrator, Dr. ConstanceCoogle (ccoogle@vcu.edu).

EVMS Frank J. Castora, PhD, and Randolph Coleman, PhDBiochemical Systems Theory Modeling of Alzheimer's Disease Using Mitochondrial Genes Involved in Amyloid Precursor Protein and Tau Processing

Mitochondrial dysfunction is a critical component in the pathogenesis of Alzheimer's Disease (AD) where deficitsin oxidative capacity and energy production have been reported. The investigators previously found abnormalexpression of several genes critical to mitochondrial energy production in AD brains. In this study, total RNAwas isolated from age-matched controls, AD and AD+ (AD possessing a mitochondrial DNA mutation) frozenautopsy brain samples, and the abnormal expression of 168 genes involved in mitochondrial function and energyproduction was assessed. A subset of mitochondrial genes was found to be critically involved in mitochondrialenergy production and function in AD brains. The investigators have now begun to build a mathematical modelof AD using Biochemical System Theory (BST). Through the development and application of appropriate differ-ential equations, the flux of various metabolites and small molecules will be simulated and used to generate atestable model of mitochondrial involvement in AD pathogenesis. (Dr. Castora may be contacted at (757) 446-5657, castorfj@evms.edu; Dr. Coleman may be contacted at (757) 221-2679, racole@wm.edu.)

UVA Alev Erisir, MD, PhD*Ultrastructural Neuropathology in Transgenic Models of Alzheimer's Disease

This investigation aimed to reveal brain alterations that are too small or too subtle to be detected by the micro-scopic tools used for studying lesions in AD. Using transgenic mice aged between 3 and 12 months that overex-press amyloid and electron microscopy (EM), the earliest alterations in brain structure were characterized prior tothe onset of cognitive decline. The brain regions known to display AD pathology were surveyed to characterizethe emergence and severity of ultrastructural lesions therein. In addition, immuno-EM was used to identify whenand where Aβ-associated neuronal deterioration started. Their systematic analyses revealed evidence of a previ-ously unappreciated culprit for the cognitive decline that emerges before 5 months of age. Particularly, the oligo-dendrocytes, the cells that make myelin, become hypermotile in the presence of overexpressed amyloid. The con-sequence is over-myelination, or rather disruptive myelination, all across the brain. Basal forebrain and entorhinalcortex, the sites of first neurodegeneration in human AD, contained oligodentrocyte hypermotility-relatedpathologies at the youngest ages. Other regions displayed progressively more severe pathologies at later ages, in aspatial pattern similar to the consensus staging protocol for the neuropathologic assessment of human AD estab-lished by the National Institute on Aging and the Alzheimer’s Association. By the ages when cell death is promi-nent, myelin outfolds gave rise to massive bulb structures, which are transitional to neuritic plaques. These resultsprovide insights into the mechanism and role of oligodentrocyte hypermotility that will guide future studies ofAD neuropathology in the human brain. (Dr. Erisir may be contacted at (434) 243-3549, ae4h@virginia.edu.)

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VCU MaryPeace McRae, PharmD, PhD, and Patricia Slattum, PharmD, PhD*Investigating the Relationship between Benzodiazepine Medications and the Development of Blood Brain Barrier Dysfunction as Risk Factors for Alzheimer's Disease

The main focus of this project was to accumulate experimental evidence that would establish a mechanism of theobserved association between benzodiazepine use and the development of AD. The goal of these studies was toinvestigate the effects of benzodiazepine medications on the integrity and function of the blood brain barrier(BBB). Utilizing the in vitro human BBB model already established in the investigator’s lab, studies confirmedthe hypothesis that select benzodiazepines alter measurements of barrier integrity. The ability of the barrier tomaintain its selectivity was only modestly affected by the benzodiazepines, and treatment with alprazolam did notresult in changes in amyloid β flux across the barrier. Further work will be conducted to examine the effects ofthe benzodiazepines on the expression of the transport proteins involved in amyloid beta passage across the BBB.(Dr. McRae may be contacted at (804) 628-5076, mpmcrae@vcu.edu; Dr. Slattum may be contacted at (804) 828-6355, pwslattu@vcu.edu.)

VPI & SU Webster L. Santos. PhD, and Gregorio Valdez, PhD*Controlling Neuronal Sphingosine-1-Phosphate as Alzheimer’s Disease Therapy

Sphingosine-1-phosphate has been shown to be a potent lipid signaling molecule that protects neurons from dyingas a result of biological insults. Six synthetic small molecules designed to specifically inhibit the activity of oneor both of the sphingosine kinases (SphK1 & SphK2) were tested on hippocampal neurons cultured under condi-tions that mimic the stress environment in brain regions affected by AD. Three compounds showed promise forpreventing pathophysiological changes in hippocampal neurons and thus promoting their long-term survival inculture. In addition, neurons treated with one of these contained more synaptic-like structures, indicating thatinhibiting these kinases either promotes the formation of new synapses or stabilizes and prevents the loss ofalready existing synapses. The investigators are currently determining the optimal dose for the designed com-pound, and testing the therapeutic benefit on cortical neurons. The data obtained should serve as the basis fordeveloping treatments for AD. (Dr. Santos may be contacted at (540) 231-5742, santosw@vt.edu; Dr. Valdez maybe contacted at (540) 526-2076, gvaldez1@vtc.vt.edu.)

GMU Catherine J. Tompkins, PhD, and colleagues*Individuals with Dementia at Adult Day Health Care Centers: Examining the Effects of Individualized Music on Mood and Agitation

The Music and Memory Program© is an international program that brings personalized music selections into thelives of people with dementia. A mixed method, six-week quasi-experimental two-group design was implement-ed to examine the effects of linking individualized treatment goals to strategic music implementation on behav-ioral and emotional functioning in a sample of older adults with dementia participating in five different adult dayhealth care centers. The results demonstrated a positive change in mood and a decrease in agitation for the inter-vention group participants based on behavioral observations. This research will increase understanding of a non-pharmacological, situation-specific individualized music intervention that can be used by formal and informalcaregivers to impact the behavior of individuals with AD. (Dr. Tompkins may be contacted at (703) 993-2838,ctompkin@gmu.edu.)

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VPI & SU Bin Xu, PhD, David Bevan, PhD, and Ling Wu, MD, PhD*Molecular Mechanisms of Amylin as a Novel Contributor to Alzheimer’s Disease

Epidemiological studies have shown a link between type 2 diabetes (T2D) and the risk for AD. A feature com-mon to both diseases is the formation of amyloid peptide aggregates. The peptide associated with AD is amyloidbeta (Aβ), and for T2D, it is amylin. Amylin can possibly travel to the brain, and aggregate themselves intoamylin amyloids, or combine with Aβ, to form amylin/Aβ-crossed amyloids. This project applied an interdiscipli-nary approach involving cellular, biochemical, biophysical, and computational methods to define the amylin amy-loid species, establish cell-based neurotoxicity assays, and assess amylin/Aβ-crossed amyloid formation and toxi-city. The investigators were able to define three amylin amyloid species that have distinct sizes and shapes. Theyfurther defined how amylin forms amyloid and fibril using multiple biochemical and biophysical methods. Theyestablished cell-based functional assays that can be used to assess amylin-induced neurotoxicity. Two compoundsused in Alternative and Complementary Medicine to treat diabetes, inflammation and neuroprotection were foundto potently inhibit amylin-induced neurotoxicity. Mechanistic insights were provided through detailed and com-prehensive cellular, biochemical, and computational simulation studies. These results serve as the basis for afuture comprehensive research program to elucidate molecular events that contribute to AD as well as to devisepotential treatment strategies. (Dr. Xu may be contacted at (540) 231-1449, binxu@vt.edu; Dr. Bevan may becontacted at (540) 231-5040, drbevan@vt.edu; Dr. Wu may be contacted at (540) 231-8442, wul3@vt.edu.)

2014-2015 Delayed Final Project Report

UVA Roberto Fernandez-Romero MD, MPH, PhDThe Neurophysiology of Driving Impairments in Early Alzheimer’s Disease

Getting lost in familiar surroundings, wandering, and unsafe driving are some of the most debilitating earlysymptoms of AD and represent a major safety concern. These visual-spatial impairments have been associatedwith a decreased capacity to perceive optic flow, the pattern of visual-motion that is naturally observed duringcommon tasks like ambulation or vehicular driving. Using an electroencephalographic technique known as eventrelated potentials (ERPs), the investigators recorded specific brainwaves that are generated by optic flow andfound significant differences between AD patients and controls. In this study they combined ERPs with a virtualreality driving test to explore the links between decreased brain responsiveness and driving capacity in a group of19 patients with early stage AD and 18 cognitively normal elderly controls. Only one patient passed the drivingtest and only one control subject failed it. A comparison of test scores showed highly significant differencesbetween the two groups, supporting the utility of virtual reality in the assessment of driving capacity. Theresearchers also found statistically significant differences in the magnitude of ERPs, with AD subjects showingsmaller responses that were also linked to poor driving scores and impaired cognitive tests. These results haveseveral implications; the differences in response magnitude between groups and their association to cognitivescores support the potential utility of ERPs as early markers of Alzheimer’s. Furthermore, the associationbetween ERPs and driving score supports the notion that impaired perception of optic flow is partly responsiblefor impaired driving capacity and suggests that ERPs may serve as screening tools. Future studies with largersamples will be necessary to generalize these findings and establish normal parameters. Longitudinal studies willalso explore the use of optic flow ERPs as markers of disease progression. (Dr. Fernandez-Romero may be con-tacted at (434) 243-5611, rf6u@virginia.edu.)

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Mountain Empire OlderCitizens TransitReceives PrestigiousAging InnovationsAward from the National Association ofArea Agencies onAging

Much of this piece appeared previ-ously in The Mountain EmpireNews, September 2016.

MEOC’s Falls Prevention in Trans-portation Program recently receivednational recognition from theNational Association of Area Agen-cies on Aging (n4a) with an AgingInnovations Award, the highesthonor presented by n4a to its over650 member agencies. The awardsprogram is sponsored by CriticalSignal Technologies Link to Life.The Falls Prevention in Transporta-tion Program was among the top 16local area agency on aging pro-grams to receive honors during then4a Annual Conference andTradeshow, July 24-28, in SanDiego, California.

The 2016 n4a Aging Innovationsand Achievement Awards recognizeArea Agencies on Aging and TitleVI Native American aging pro-grams that develop and implementcutting-edge approaches to supportolder adults, people with disabilitiesand their family caregivers. A partof the criteria for selection of thehonorees was the ease with whichother agencies could replicate theprogram in their communities.

The Falls Prevention Program wasa collaborative effort of Mountain

Empire Older Citizens’ Program ofAll-Inclusive Care for the Elderly(PACE), MEOC Transit, and theVirginia Geriatric Education Center(VGEC), a consortium of VirginiaCommonwealth University, Univer-sity of Virginia, and Eastern Vir-ginia Medical School. The Consor-tium includes staff from medicine,pharmacy, nursing, occupationaltherapy, physical therapy, and socialwork who work together as aninterprofessional group of equalswho oversee all of the consortium’sgeriatrics training programs. Theconsortium has been federally fund-ed and supported by the HealthResources and Services Administra-tion (HRSA) of the Department ofHealth and Human Services since2010.

MEOC’s award winning Falls Pre-vention in Transportation Programis one of many positive results ofthe seven-week evidence basedpractice training program on fallsprevention conducted by VGEC tothe Interdisciplinary Team and staffat Mountain Empire PACE. EdAnsello, PhD, Director of theVGEC as well as the Director of theVirginia Center on Aging at Vir-ginia Commonwealth Universitysaid, “The interdisciplinary staff atMEOC’s PACE is an especiallyimpressive team. MEOC had theforesight to include in our seven-week training program on falls pre-vention various employees whotouch the lives of the older personsin the PACE program, includingthose in transportation.”

MEOC seized the opportunity totake the VGEC training to all itsfrontline employees and provided afalls prevention class focused oneducating PACE, Transit, and Per-

sonal Care staff on preventing fallsand how they impact service andliability. The sessions included dis-cussion of risk factors, care plan-ning, teamwork, interventions andimplementation. As a direct resultof the training and the implementa-tion of the evidence based practicesin the daily work of MountainEmpire Transit, there was a 24%reduction of falls in the third quar-ter and a 40% decrease in falls inthe fourth quarter.

Michael Wampler, Executive Direc-tor of MEOC, said, “We are verygrateful to have received this n4aInnovations Award. We share thishonor with many partners andwould like to especially thank VCUand VGEC for providing invaluableand critical assistance with the pro-ject. Falls prevention is of greatimportance to the health, safety, andquality of life of those we serve.”

Dr. Ansello noted, “Our trainersencountered enthusiasm and com-mitment to the well-being of olderadults in all of our interactions atMEOC PACE. Moreover, weenjoyed firsthand the warmth andhospitality of its leadership.”

PACE Executive Director TonyLawson said, “VGEC’s evidence-based falls prevention training pro-gram helped PACE staff understandand evaluate practices in use byhealthcare providers around theworld. The training helped us ruleout ineffective practices and focuson interventions that are known toprevent falls.” Lawson added, “Theongoing geriatric teleconsults withVCU faculty are helping our clini-cal team stay current on importantgeriatric issues like poly-pharmacyand antibiotic-resistant organisms.

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The more we know, the better wecan care for participants in thePACE program.”

“With the health care landscapecontinuing to change rapidly, ourmembers are discovering new waysto position themselves in the long-term and health care marketplaces,as well as to strengthen long-stand-ing services, to meet the needs ofAmerica’s rapidly growing olderadult population,” said n4a’s ChiefExecutive Officer Sandy Mark-wood. “Our members work tireless-ly, and with little fanfare in theircommunities, and this programenables us to shine a well-deservedspotlight on their critical work tosupport older adults’ health, safety,independence, and dignity,” Mark-wood added.

In conclusion, Dr. Ansello shared,“Happily we have been funded byHRSA for another three years andare continuing this positive rela-tionship with MEOC PACE. Ourcurrent interactions include staffand caregiver training events andbi-monthly geriatric consults whereMEOC PACE identifies issuesneeding clarifications and training,and our VGEC identifies and sup-plies the experts to deliver these viateleconferencing. We have foundour partnership with MEOC PACEto be most positive and beneficialfor older adults.”

MEOC has been providing servicesto older adults and their caregiversin Lee, Wise, and Scott Countiesand the City of Norton since 1974.MEOC’s Program of All-InclusiveCare for the Elderly, one of the veryfirst rural PACE programs in thecountry, opened its doors over eightyears ago.

Representatives of MountainEmpire Older Citizens, Inc.(MEOC) accept a National Associ-ation of Area Agencies on Aging(n4a) Aging Innovations andAchievement Award for MEOC’sFalls Prevention in TransportationProgram. Left to right are HeatherSellar, Critical Signals TechnologyVice President of Managed Careand Independent Living, MichaelWampler, MEOC Executive Direc-tor, Mitch Elliott, MEOC TransitDirector, 2014-2016 n4a PresidentJoe Ruby and Tony Lawson, MEOCPACE Director.

Websites for OlderAdults Taking Medications

As we age, it’s likely that some ofus have more prescriptions in ourdaily regimen than we used to.

Aging may coincide with havingseveral health issues simultaneous-ly, so we are seeing more than onehealth care provider, and we receiveprescriptions from each of them.Such concurrent conditions mostlikely mean we’re taking multiplemedications from different drugclasses. The result can be that thesedrugs interact with each other orwith foods in our diet or produceadverse drug reactions (ADRs).

There’s an excellent website to helpolder adults manage them and bealert to troublesome possibilities. Ismy prescription drug problematicfor older patients, even though it’seffective with those who areyounger? Is my prescription med-ication likely to interact with otherdrugs or with certain foods? Are theADRs likely to be seen as a newcondition, prompting my healthcare prescriber to order still anothermedication?

Drugs.com maintains up-to-dateinformation on more than 24,000prescription, over the counter, andherbal drugs. Its website containssuch features as an A-Z drug index(alphabetical search of drugs, withdosage, interactions, side effects,etc.); a pill identifier, where youtype in a pill’s color, shape, andanything imprinted on it to learnwhat it is; a News & Alerts section

- continued on p. 17

Would You Like toReceive Age in

Action Electronically?

We currently publish Age inAction in identical print and PDFverions. Age in Action is transi-tioning over time to an electronicversion only. You can subscribeat no cost. Simply e-mail us andinclude your first and last namesand your best e-mail address. Ifyou now receive hard copies bypostal mail, please considerswitching to e-mail distribution.Send an e-mail listing yourpresent postal address and beste-mail address for future deliver-ies. Send requests to Ed Anselloat eansello@vcu.edu.

Medicare AdvantagePlans May RecoverConditional PaymentsUnder the MedicareSecondary Payer Act

by Andrew H. Hook, CELA and Shannon A. Laymon-Pecoraro,Esq., Hook Law Center, Virginia

Beach and Suffolk

The following first appeared inHook Law Center News, May 31,2016, and is reprinted with permis-sion. But first, some context subse-quently provided by co-authorShannon Laymon-Pecoraro:

Let's say John is over the age of 65and enrolled in Medicare and hasAnthem as a Medicare AdvantagePlan (MAP). John is in an automo-bile accident that breaks his hip,requiring surgery and extensiverehab. Medicare ($100,000) and hisMAP ($50,000) pay for the surgeryand rehab. John's attorney getsJohn a $500,000 settlement fromthe other driver. Traditionally, onlythe Medicare lien (for lack of a bet-ter term) of $100,000 would havebeen due (to be reimbursed or“recovered”). Under this new case,the MAP's lien of $50,000 is alsodue. If the attorney fails to properlypay off the conditional payments,John and John's attorney could bepenalized.

In an effort to reduce governmentspending and preserve the Medicareprogram, Congress enacted theMedicare Secondary Payer(“MSP”) Act in 1980. Prior to thattime, Medicare was the primarypayer for any covered medicalexpense, the only exception beingthose persons covered by Worker’s

Compensation. With the adoptionof the MSP Act, Medicare’s respon-sibility for medical expenses isreduced to only those expenses notcovered from another source, suchas another insurance plan, whichincludes health, Worker’s Compen-sation, automobile, liability, and no-fault insurance plans, known as aprimary plan. As a result, Medicarecan recover any payments that havebeen made, or can reasonably beexpected to be made, that are theresponsibility of a primary plan.

In cases when it is expected that theprimary plan will either not pay forservices or not pay promptly,Medicare may make conditionalpayments, thereby creating aMedicare lien. This lien must thenbe repaid by a primary plan or anyentity that receives a third-partypayment. The MSP Act thereforeaffects everyone involved in a MSPclaim, including, but not limited to,any beneficiary, provider, physi-cians, state agency or attorney. Fail-ure to comply with this requirementcould result in Medicare’s ability torecover double damages.

For years, there has been a debatewith regard to whether the MSP Actextends to private companies thatcontract with Medicare, typicallyunder what is referred to as aMedicare Advantage Plan(“MAP”). Under a MAP, an indi-vidual elects to receive Medicareservices from an insurance compa-ny of his choosing, Medicare paysthe MAP a fixed fee, and the MAPassumes the insurance risk by pro-viding Medicare Part A and B ser-vices. The United States DistrictCourt for the Eastern District ofVirginia recently held that aMedicare Advantage Plan has a pri-

vate right to recover under the MSPAct, and may pursue recovery fromany entity that receives paymentfrom a primary plan.

In Humana Insurance Co. v. ParisBlank, LLP, Humana, which madeconditional payments as a MAP,sought recovery from various par-ties, including Paris Blank, LLP, alaw firm representing a Plaintiff ina personal injury action as a resultof an automobile accident. ParisBlank argued that Medicare was aprivate insurance company, and as aresult, was not entitled to recoverunder the MSP Act, and specifical-ly, that recovery could not be madeagainst the law firm. Citing In reAvandia and a memorandum fromthe Centers from Medicare & Med-icaid Services, the court essentiallydetermined that Medicare, in con-tracting with the MAP, assigns theMAP its rights and responsibility inrecovering from a primary plan.

The Court then reasons thatalthough the attorneys are not theprimary plan, the MSP Act extendsto any entity, including attorneys orlaw firms, receiving payment fromthe primary plan, and that as aresult, the MAP could recover froman attorney who was paid from theproceeds of a personal injury settle-ment.

(Editor: So, for those who haveboth Medicare and a MedicareAdvantage Plan, the latter mustnow be seen in a new light whenthere are personal injuries and lawsuits.)

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Chocolate and Health

There have been somany headlines andgossip buzzes aboutthe benefits of eating

chocolate that you’d think weshould add candy bars to the fourbasic food groups. Not so fast.

First, it’s not chocolate itself whichdeserves whatever praise may ormay not be warranted. It’s cocoaflavanols that may be the source ofhealth benefits. Flavanols are bioac-tive plant based nutrients that arealmost totally free of calories,sugar, and fat. Chocolate is a com-bination of cocoa solids, cocoa but-ter or other fat, and sugar. Milk inthe form of milk powder or con-densed milk is added to make milkchocolate, while cocoa solids areheld back to make white chocolate.Worth noting is that, in makingsome forms of chocolate, the pro-cessing can destroy the cocoa fla-vanols.

Small studies in 2013 and 2014suggested that the naturally occur-ring flavanols in cocoa beans mayhelp to improve blood flow andlower blood pressure and may havehelped subjects in their 50s and 60sremember and recognize visual pat-terns more quickly than counter-parts given placebos over threemonths.

But how and where do we findthese cocoa flavanols? The answeris that it’s not always easy nor prac-tical. To get 750 mg of flavanol (anamount used in some of the studies)would require approximately: 6tablespoons of cocoa powder, about70 calories; or 5 ½ ounces of semi-

sweet chocolate chips, about 740calories; or 4 ¾ ounces of darkchocolate, about 750 calories; or 2½ pounds of milk chocolate, about5,850 calories! And we’d have toconsume this every day.

This would also mean that we areingesting all the sugar and fatsadded in the recipes for these vari-ous forms of chocolate. A veryunhealthy way of trying to gethealthy.

So, a new research trial has begunat Harvard Medical School entitledCOSMOS (COcoa Supplement andMultivitamins Outcomes Study),directed by Drs. JoAnn Manson andHoward Sesso. It’ll give 750 mg aday of cocoa flavanols (in capsules,free of additives) to 18,000 women(ages 65 and above) and men (ages60 and above) for four years.

This randomized trial of cocoa fla-vanols is the first large scale studyto test whether or not cocoa fla-vanols deserve the health benefitsascribed and do, indeed, help lowerthe risk of heart attacks, strokes,and cardiovascular deaths. So fornow, we really don’t know whethercocoa flavanols protect the heartand brain.

Chocolate and health? We’ll have towait to find out.

10 Ways to Love Your Brain

Start Now. It’s never too late or tooearly to incorporate healthy habits.

Hit the Books. Formal educationwill help reduce risk of cognitivedecline and dementia. Take a classat a local college, community cen-ter, or online.

Butt Out. Smoking increases riskof cognitive decline. Quittingsmoking can reduce risk to levelscomparable to those who have notsmoked.

Take Care of Your MentalHealth. Some studies link depres-sion with cognitive decline, so seektreatment if you have depression,anxiety or stress.

Heads Up! Brain injury can raiserisk of cognitive decline anddementia. Wear a seat belt and usea helmet when playing contactsports or riding a bike.

Follow Your Heart. Risk factorsfor cardiovascular disease andstroke (obesity, high blood pressureand diabetes) negatively impactyour cognitive health.

Fuel up Right. Eat a balanced dietthat is higher in vegetables and fruitto help reduce the risk of cognitivedecline.

Catch Some ZZZZs. Not gettingenough sleep may result in prob-lems with memory and thinking.

Break a Sweat. Engage in regularcardiovascular exercise that ele-vates heart rate and increases blood

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flow. Studies have found that physi-cal activity reduces risk of cogni-tive decline.

Stump Yourself. Challenge yourmind. Build a piece of furniture.Play games of strategy, like bridge.

Buddy Up. Staying sociallyengaged may support brain health.Find ways to be part of your localcommunity or share activities withfriends and family.

Growing evidence indicates thatpeople can reduce their risk of cog-nitive decline by adopting keylifestyle habits. When possible,combine these habits to achievemaximum benefit for the brain andbody.

Visit www.alz.org/10ways to learnmore.

Geriatrics WorkforceTraining Grants Available

The Virginia Center on Aging(VCoA) has begun its 11th year asadministrator of monies to trainpersonnel to be better prepared tomeet the needs of older Virginians.Former Delegate Jack Reidpatroned the bill establishing theGeriatric Training and Education(GTE) initiative to develop astronger geriatrics and gerontologi-cal work force in the Common-wealth. The General Assembly ofVirginia has appropriated funds tocontinue this program during fiscalyear, July 1, 2016 to June 30, 2017.

The General Assembly has desig-nated the VCoA as administrator ofGTE. In order to put these GTEmonies to their most effective andprudent use, we issue a Request forProposals from Virginia institutionsof higher education, community-based organizations, and other not-for-profit groups with a strong his-tory of adult and aging-relatedexperience. Applicants submit pro-ject proposals at either of two sub-mission deadlines: August 1st orNovember 1st. Application guide-lines are available on the VCoAwebsite (www.sahp.vcu.edu/departments/vcoa) under Programs.

Eligible applicants apply for GTEfunds for workforce training andeducation initiatives that can becompleted within the fiscal year.Applications for training projects,conferences, or similar educationalprograms are appropriate. Appli-cants may request GTE awards of$1,000 to $25,000, as long as therequest is justified. VCoA uses

objective third-party reviewers inthe award selection process. Thenumber of awards made dependsupon the availability of funds.

See the website for guideline in for-matting the application and lists ofthe past 10 years’ awardees andtheir topics of training and educa-tion. The next application deadlineis November 1, 2016.

Websites, continued

that has information on new appli-cations of existing drugs, FDA Alerts, and drug shortages; an inter-active list of the Top 100 Drugscurrently in use; and other optionsfor consumers and professionals.

Suppose you are taking Atorvas-tatin prescribed by your cardiolo-gist. Clicking this medication onthe Top 100 Drugs tab, for instance,gives you information on what thisdrug is and its intended purpose; itsgeneric and brand names; consider-ations before starting the drug; howto take it; what happens if you missa dose; what you should avoidwhile taking atorvastatin; sideeffects; dosing information; druginteractions; geriatric considera-tions, and more. The same formatapplies for not only the 100 TopDrugs but also for all drugs in thehuge index.

AdultMeducation.com is a websitedeveloped and maintained by theAmerican Society on Aging and theAmerican Society of ConsultantPharmacists Foundation. The sitefocuses on medication adherence,meaning the person’s actions tocontinue taking appropriate drugs.

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October 16-19, 201667th Annual Convention and Expoof the American Healthcare Associ-ation and the National Center forAssisted Living. Nashville, TN. Forinformation, visitwww.eventscribe.com/2016/ahcancal/index.asp.

November 4, 2016Fundamentals in Leadership Train-ing for Healthcare Professionals.Presented by CommonHealth Part-ners. Contact hours (6) sponsoredby VCU’s Department of Gerontol-ogy. 10:00 a.m. – 2:00 p.m. Cost:$185. Mariners Landing, Huddle-ston, VA. For information, e-mailJay@commonhealthpartners.comor visit https://training.vcu.edu/course_detail.asp?ID=15380.

November 10, 2016Conference on Dementia: Enhanc-ing Quality of Life in DementiaCare. Presented by Alzheimer'sAssociation Central and WesternVirginia Chapter. 8:00 a.m. - 5:00p.m. Holiday Inn Valley View,Roanoke. For information, call(434) 973-6122 ext. 103 or visitwww.alz.org/cwva.

November 10, 2016The Art of Healthy Aging Forumand Expo: The Joys and Chal-lenges of Caregiving. Presented bySenior Services of SoutheasternVirginia. Virginia Beach Conven-tion Center. For information, visit www.ssseva.org.

November 15-16, 201633rd Annual Conference and TradeShow of The Virginia Associationfor Home Care and Hospice. Mar-riott City Center, Newport News.For information, visitwww.vahc.org.

November 16, 2016The RVA Better Aging Forum.Kathy F. Berry, Chaplain - West-minster Canterbury Richmond, willdiscuss how family members andcaregivers can address the spiritualneeds of older adults with demen-tia. Senior care/product/serviceindustry professionals are invited.11:30 a.m. - 1:00 p.m. The VirginiaRoom, Imperial Plaza, Richmond.For information, call (804) 368-3200 or e-mailJWarns@RFSLends.com.

November 16-20, 2016 Annual Scientific Meeting of theGerontological Society of America.New Orleans Marriott and Shera-ton New Orleans, New Orleans,LA. For information, visitwww.geron.org.

January 25, 2017Virginia Center on Aging’s 31stAnnual Legislative Breakfast. St.Paul's Episcopal Church, Rich-mond. 7:30 a.m. - 9:00 a.m. Forinformation, call (804) 828-1525 ore-mail eansello@vcu.edu.

March 9-12, 2017The Future Is Here: Educating aNew Generation of Professionals inAging Worldwide. The 43rd Annu-al Meeting and Educational Lead-ership Conference of The Associa-tion for Gerontology in HigherEducation. Miami Marriott Dade-land, Miami, FL. For information,visit www.aghe.org.

March 20-24, 2017Aging in America: Annual Confer-ence of the American Society onAging. Chicago, IL. For informa-tion, visit www.asaging.org.

April 4-5, 2017Virginia Assisted Living AnnualSpring Conference and TradeShow. DoubleTree by Hilton,Williamsburg, VA. For informa-tion, visit www.valainfo.org.

April 6-9, 201738th Annual Meeting of The South-ern Gerontological Society. DoubleTree by Hilton AshevilleBiltmore, Asheville, NC. Forinformation visit www.southerngerontologicalsociety.org.

April 21-23, 2017The 28th Annual Virginia Geri-atrics Society Conference. ShortPump Hilton, Richmond. For infor-mation, visit www.virginiageriatricssociety.org.

May 22-23, 2017Governor’s Conference on Aging.Hotel Roanoke, Roanoke. Forinformation, visit www.dars.virginia.gov.

Age in ActionVolume 31 Number 4

Fall 2016

Edward F. Ansello, Ph.D. Director, VCoA

James A. RothrockCommissioner, DARS

Kimberly S. Ivey, M.S.Editor

Age in Action is published quarter-ly. Submissions, responses to casestudies, and comments are invitedand may be published in a futureissue. Mail to: Editor, Age in Action,P.O. Box 980229, Ricmond, VA23298-0229. Fax: (804) 828-7905.E-mail kivey220@yahoo.com.

Winter 2017 Issue Deadline: December 15, 2016

Calendar of Events

18

Virginia Center on Agingat Virginia Commonwealth University, Richmond, Virginiawww.sahp.vcu.edu/vcoa

Staff:Director

Edward F. Ansello, PhDElderhostel Coordinators

Catherine Dodson, MS - RichmondBarbara Wright - Staunton

Associate Director for ResearchConstance L. Coogle, PhD

Elderhostel/Road Scholar Program Administrator Jeffrey Ruggles, MFA

Project DirectorPaula Knapp Kupstas, PhD

Lifelong Learning InstituteRachel Ramirez

Assistant Director, Virginia Geriatric Education CenterBert Waters, PhD

Project CoordinatorsCourtney O’Hara, MEdRuth Anne Young, MEd

Research AssociatesSung Hong, PhDMyra G. Owens, PhD

Research AssistantJenni Mathews

Administrative AssistantDevanee Beckett

Editor, Age in ActionKimberly S. Ivey, MS

Advisory Committee:Paul F. Aravich, PhDFrank Baskind, PhDRussell H. Davis, PhDCecil Drain, PhDJonathan Evans, MDJames Hinterlong, PhDPaul G. Izzo, JDChristine Jensen, PhDAdrienne Johnson, MSRichard W. Lindsay, MDChristopher M. McCarthy, EsqHon. Jennifer L. McClellanKenneth J. Newell, MSHon. John O'BannonSherry PetersonSaundra C. Rollins, MSSWJim RothrockDavid SadowskiRobert L. Schneider, PhD, ChairmanRalph E. Small, PharmDBeverley SobleThelma Bland Watson, PhD

Virginia Department for Aging andRehabilitative Serviceswww.dars.virginia.gov

Staff:Commissioner: Jim RothrockDevin Bowers, Dementia Services CoordinatorTanya Brinkley, Service Referral / Administrative AssistantTim Catherman, MHA, Director, Aging OperationsBrenda Cooper, Program and Compliance AnalystLeonard Eshmont, PMP, Director, Information TechnologyJacqueline Freeze, External Aging Services AuditorBet Gray, ASAPS ProgramElizabeth Havenner, MSW, Program CoordinatorApril Holmes, MS Ed, Prevention Program for Older AdultsDavid Hominik, Legal Services DeveloperJanet James, Esq., Public Guardian Program CoordinatorNicole Keeney, RD, LDN, Nutrition Program CoordinatorGeorgie Lewis, Customer Service SpecialistNancy Lo, MSW, GrandDriver CoordinatorAmy Marschean, JD, Senior Policy AnalystChristy Miller, PMP, CSTE, NWD IT/Business AnalystKathy Miller, RN, MS, MSHA, Director of ProgramsCarolyn Mines, No Wrong Door Help Desk Katie Roeper, Assistant CommissionerAnnette Sherman, Systems AnalystCecily Slasor, Administrative Program SpecialistPam Smith, VICAP DirectorAnita Squire, Commonwealth Coordinated Care EducatorMary Strawderman, Lifespan Respite Voucher Grant AssistantKathleen Vaughan, MA, No Wrong Door CoordinatorErika Yssel, No Wrong Door

Commonwealth Council on Aging:Members

Kyle R. Allen, DO, AGSFBeth Barber, ChairMitchell Patrick DavisDavid M. FarnumJoni C. GoldwasserCarter HarrisonValerie L’Herrou, JDRichard W. Lindsay, MDShewling MoyDiana M. PaguagaValerie Price, Vice-ChairRoberto QuinonesKathryn B. ReidBeverley SobleVernon WildyVeronica WilliamsErica Wood, Esq

Ex Officio MembersThe Hon. William A. Hazel, Jr., MD , Secretary of Health and

Human ResourcesWilliam Massey, VAAAAJames A. Rothrock, DARSTerry A. Smith, DMASTara Ragland, VDSS

19

Virginia Commonwealth University Age in ActionVirginia Center on AgingP.O. Box 980229Richmond, VA 23298-0229

Return Service Requested

Nonprofit OrganizationU.S. POSTAGE PAID

Permit No. 869RICHMOND, VIRGINIA

Virginia Commonwealth University is an equal opportunity/affirmative action institution and does not discriminate on thebasis of race, gender, age, religion, ethnic origin, or disability. If special accommodations are needed, please contact Dr. Edward F. Ansello, VCoA, at (804) 828-1525.

Refresh, Refuel, and Retool: An Alzheimer's Workshop for CaregiversPresented by The Community Idea Stations

November 17, 2016The Community Idea Station, Richmond

8:30 a.m. - 4:30 p.m.

This interactive workshop will be a time of engagement for family caregivers with experts in the field ofAlzheimer’s and Dementia. Sessions will explore positive approaches to living with the disease from the per-spective of the caregiver as well as the loved one with Alzheimer’s. Built into the day will be time for sharingand discussion of each person’s unique journey.

Presentations include:

• Alzheimer's: Understanding the Disease, the Science, and the Latest Research and Treatments• Learn to Speak Dementia• Enjoyment and Engagement in Life: How to Provide Meaningful Activity for a Person with Dementia• Friendships: How to Encourage Others to Be a Better Friend to You and Your Loved One

Registration fee is $15 and includes a continental breakfast and lunch. Each participant will leave with a Care-giver’s Tool Kit to take home. For information, visit www.ideastations.org.