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Should you tell someone with Alzheimer’s that a close friend has died?

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February 29, 2012

- Alzheimer's Care, Blog, Elder Law Articles

This has been the subject of open debate for a while. The short answer is: It really depends on the person. If it’s your loved one involved, you know him or her better than anyone. If you think he or she can handle it, then the answer is you probably should share news of the friend’s death. Important considerations include thinking how the news will affect your loved one and whether there will be any benefit to it. You also have to consider how well your loved handles stressful situations. If the deceased is someone your loved one has seen regularly, then it might be best to share the news. After that, you are still likely to be asked about the person’s whereabouts, due to short-term memory loss. Then, you have to ask yourself if it’s worth it to keep repeating news of the death or if it’s time to exercise the right to use “therapeutic fibs.” These are always used to protect the person with dementia. See how it goes after you tell your loved one about the death and take it from there. If questions persist about the deceased, you can (honestly) say that the person just “isn’t here right now.” Or you can say in an assuring tone that although you’re not sure where the person is, you are sure he or she is OK and in a safe place. Whether or not to talk about a death also depends on how far Alzheimer’s has progressed. With later stage dementia, it probably isn’t beneficial. Regardless of the stage, if your loved one wasn’t particularly close to or frequently around the deceased, it might not be to your benefit to raise the subject. The same thought process comes into play if your loved one inquires about his or her parents. Even if the parents have died long ago, your loved one’s long-term memory might be kicking in, bringing them more prominently to mind. Validation is the best strategy to use when this happens. Say, “I know your parents aren’t here now and you miss them, but they are OK and they know where you are.” Then, you can reminisce. For more information about communicating with a loved one with dementia, please click here to listen to a Jo Huey speak on this very delicate subject.  It is a very informative discussion available free as an mp3.
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Implementation by the Illinois Department of Health and Family Services of the Federal Deficit Reduction Act of 2005 (DRA) © 2011 – Part II

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February 27, 2012

- Blog, Elder Law Articles, Medicaid and Paying for Nursing Home Care

I.          Introduction The following  is Part II of a three part article first appearing on February 9, 2012 summarizing the implementation by the Illinois Department of Health and Family Services (Department) of the Federal Deficit Reduction Act of 2005 (DRA). Much has been written about these rules over the last several years by various members of the Elder Law Section Council and also other Section Councils. This article will deal mainly with the final rules as adopted in the State of Illinois (ILDRA). This article will be issued in three parts, which will be found in three issues of the Section Council newsletter. The first part dealt with the scope of the federal changes and five specific areas of Illinois law that have been impacted by the new Illinois rules. This second installment deals with six more areas in Illinois law that have been changed. The third and final installment will deal with the last three areas of Illinois law that have been changed by the adoption of these new rules. The author struggled with the choice of either making this article a short, cursory discussion of the DRA or a long version discussing the DRA and related rules in greater detail. Through discussion with the newsletter staff, we opted for the longer discussion. The reason for this decision is that a short discussion would not address the numerous issues and nuances found in the new provisions and, thus, be rather useless to a practitioner. The longer version, while more time-consuming to digest and use, will hopefully provide a way of reading the new law that is, perhaps, slightly more convenient than reading the statue itself, while not glossing over or missing any of the nuances and issues on which our clients’ cases often turn. This was our intention. Further, it should be noted that much of this article deals with changes that were not part of the DRA. However, because the practitioner reading this article is presumably interested in the Illinois Administrative Rules dealing with long-term care cases and how they are impacted by DRA, a discussion of some of the provisions not mandated by DRA, but nevertheless inserted into this rule change by the state of Illinois, will also be discussed for a more for complete discussion that is relevant for the practitioner. Section 120.347- Treatment of Trusts and Annuities. Subsection a) This Section deals with the treatment of trusts established on or after August 11, 1993. Subsection b) This Section provides that a trust is any arrangement which a grantor transfers property to a trustee or trustees with the intent that it be held and managed or administered by the trustee for the benefit of the grantor or designated beneficiaries. This seems to focus on self settled trusts. The Section indicates a trust also includes any legal instrument or device that is similar to a trust, including an annuity. Subsection c) This Section states that a person shall be considered to have established a trust (and hence the trust is available resource for the person) if the resources of the person were used to form all or part of the principal of the trust and the trust is established (other than by Will) by any of the following:
  1.  the person,
  2.  the person’s spouse; or
  3. any other person, including a court or administrative body with legal authority to act on behalf of or at the direction of the person or the person’s spouse.
Before describing the exceptions to this general rule, it should be noted that the other than by will exception would exclude bypass wills and pour back trusts. Subsection d) This Section provides certain exceptions as to when this section does not apply to certain trusts.
  1. Two exceptions are what is commonly referred to as (d)(4(A) irrevocable trusts and (d)(4)(C) irrevocable trusts. These trusts are the self settled OBRA trusts that are created by an individual for their own benefit.
The section then goes on to describe that for revocable trusts, the Department shall treat as an available resource the amount of the trust from which payment to or for the benefit of the person could be made.  Subsection e) This Section provides that subsections f and g that follow below apply to the portion of the trust attributable to the person and without regard to:
  1.  the purpose of the trust,
  2.  whether the trustee has or exercises any discretion under the trust; or
  3.  whether there are any restrictions on distributions or use of distributions from the trust.
Subsection f) This Section deals with revocable trusts and indicates that the Department shall:
  1. treat the principal as of an available resource
  2. treat as income payments from the trust that are made to or for the benefit of the person, and
  3. treat any payments from the trust is transfers of assets by the person (subject to the provisions of Section 120.387 or 120.388).
Subsection g) This Section provides for the treatment of irrevocable trusts, and indicates that the Department shall:
  1. treat as an available resource the amount of the trust for which payment to or for the benefit of the person could be made,
  2. treat as income payments from the trusts that are made to or for the benefit of the person,
  3. treat any other payments from the trust is transfers of assets by the person   (subject again to section 120.387 or 120.388; and
  4.  treat as a transfer of assets by the person the amount of the trust for which no payment could be made to the person under any circumstances. The date of the transfer is the date the trust was established or, if later, the date that payment to the person was foreclosed. The amount of the trust is determined by including any payments made from the trust after the date that payment to the person was foreclosed.
Subsection h) This Section deals with the treatment of trust income. It indicates that for married couples, income from trusts shall be attributable to each spouse as provided in the trust unless:
  1. payment of income is made solely to one spouse, in which case the income shall be attributed to that spouse;
  2. the payment of income is made to both spouses in which case one half of the income shall be attributed to each spouse, or
  3. the payment of income is made to either spouse, or both, and to another person or persons, in which case the income shall be attributed to each spouse in proportion to the spouse’s interest, or if payment is made to both spouses and no such interest is specified, one half of the joint interest shall be attributed to each spouse.
Subsection i) Annuities are treated similar to trusts. What the Department apparently means by this is the following:
  1. revocable and assignable annuities are considered available resources
  2. any portion of an annuity for which payment to or for the benefit of the person or the persons house could be made is an available resource. Also, an annuity that may be surrendered to its issuing entity for a refund or payment of a specified amount or provides for a lump sum payment settlement option is an available resource valued at the amount of any such refund, surrender or settlement.
  3. Income received from an annuity by an institutionalized person is considered non-exempt income. Income received by the community spouse of an institutionalized person is treated as available to the community spouse for purposes of determining the community spouse income allowance under 120.379(e).
  4. An annuity that fails to name the State of Illinois as a remainder beneficiary as required under 120.385(b) shall result in denial or termination of eligibility for long-term care services.
Subsection j) This Section indicates that the principal of a trust established under the self-sufficiency trust fund program (set forth under 20 I LCS 1705/21.1) is an exempt resource . See the further discussion and annuities later in this article when we discuss when the transfer of assets in exchange for a and other assets such as an annuity or promissory note is considered to be a transfer for fair market value and hence not a penalizable uncompensated transfer. Section 120.379- Provisions for the Prevention of Spousal Impoverishment. Subsection a) indicates that this Section applies only to an institutionalized person whose spouse resides in the community. For purposes of this paragraph, institutionalized individuals or persons are defined in section 120.388(c). Section 120.380(c) defines institutionalized persons as persons residing in long-term care facilities, including those who were residing in the community at the time a transfer of assets was made or persons who but for the provision of home and community based waiver services would require the level of care in a long-term care facility, including those persons receiving home and community based waiver services were not receiving the services at the time the transfer was made.   Subsection b) Income. This subsection describes the treatment of income in determining the financial eligibility of an institutionalized spouse The Section provides that in determining the financial eligibility of an institutionalized spouse, only non-exempt income attributed to the institutionalized spouse shall be considered available. The Section goes on to describe how income is allocated between spouses based on certain rebuttable presumptions dealing with:
  1. if payment is made solely in the name of one spouse , the income will be considered available only to that spouse,
  2. if payment of income is made in the name of both spouses, one half of the income shall be considered available to each spouse,
  3. if payment of income is made in the names of either spouse, or both, and to another person or persons, income shall be considered available to each spouse in proportion to the spouse is interest or if payment is made to both spouses and no other interest is specified then one half of the joint interest shall be considered available to each spouse
  4. if payment of income is made from a trust income shall be considered to each spouse as provided under 120.340 7H
  5. if there is no trust or instrument establishing ownership, one half of the income shall be considered available to institutionalized spouse and one half the community spouse.
Subsection c) Resources. In determining the financial eligibility of an institutionalized spouse, the following rules apply:
  1. At the beginning of a continuous period of institutionalization, and the total value of resources owned by either or both spouses shall be computed.
  2. The Department, at the beginning of a continuous period of institutionalization  and at the request of the institutionalized spouse, community spouse, or a representative of either, shall conduct an assessment of the couple’s resources for purposes of determining the combined amount of non-exempt resources in which either spouse has an ownership interest area person requesting the assessment shall be responsible for providing documentation and verification. For purposes of this subsection a continuous period of institutionalization is defined as at least 30 days of continuous institutional care. The Section goes on to describe for how long that initial assessment remains effective if there are discharges from a long-term care facility, hospitalization etc.
  3. For purposes of this subsection (c) a continuous, a continuous period of institutionalization is defined as at least 30 days of continuous institutional care. An initial assessment remains effective during that period if:

       a.  a resident of a long-term facility is discharged for a period of less than 30 days and then re-enters the facility;

         b.  a resident of a long-term care facility enters a hospital and then returns to the facility from the hospital;

         c.  a person discontinues receiving home and community case-based services for a period of less than 30 days; or

         d. a person discontinues receiving home and community-based services due to hospitalization and then is

    discharged to receive home and community-based services.            .

     4.    At the time of the institutionalized spouse’s application for medical assistance, all non-exempt resources held by either the institutionalized person, the community  spouse or both are considered available to the institutionalized spouse. From this amount may be deducted and transferred to the community spouse the Community Spouse Resource Allowance ( CSRA). This means that at all assets of both spouses are added up, and then $109,560 is allocated to the community spouse, and the rest is considered an available resource to the institutionalized spouse. Subsection d)  Transfer of resources to the community spouse. From the amount of non-exempt resources considered available to the institutionalized spouse, a transfer of resources is allowed by the institutionalized spouse to the community spouse or to another individual for the sole benefit of the community spouse in an amount that does not exceed the CSRA i.e. $109,560. The CSRA is further defined to be the difference between the amount of resources otherwise available to the community spouse and the greater of:
  1. the amount established annually by the US Department of Health and Human Services, which as of January 1, 2011 was $109,560,
  2. the amount established through a fair hearing under subsection (f)(3)F3 of this Section, or
  3. the amount transferred under a court order against an institutionalized spouse for support of the community spouse.
Subsection e) Deductions are allowed from an institutionalized spouse’s post-eligibility income for the community spouse income allowance and family allowance as set forth in Sections 120.60 1(d) and (e). Subsection f) In this Section, there is a discussion of fair hearings that either the institutionalized spouse orr the community spouse may request if there is dissatisfaction with  the CSRA allowance, or if there is a request  for an increase in the MMMNA (Minimum Monthly Maintenance Needs Allowance). Subsection g) This Section describes the appeal of a fair hearing. Subsection h)   If a transfer of resources as permitted under subsection (d) is made from the institutionalized spouse to the community spouse, then such transfer shall be made as soon as practicable after the date of the initial determination of eligibility and before the first regularly scheduled redetermination of eligibility, taking into account such time as baby necessary to obtain a court order under subsection (d)(3) of this Section. If the transfer of resources has not been made by the first scheduled redetermination and no petition for an order the spousal report support is pending judicial review, the resources shall be considered available to the institutionalized spouse Subsection  i) This Section deals with assignment of support rights and generally deals with the concept of spousal refusal, which is very controversial in the formation of these rules. The concept of spousal refusal is grounded in federal law.  There has been litigation regarding this in other states, and depending on how this provision is administered, it could be controversial here in Illinois as well. This Section indicates that the institutionalized spouse shall not be ineligible by reason of resources determined under Section (c)(4) to be available to the cost of care when: 1. institutionalized spouse has assigned it to the state any rights to support from the community spouse, 2. the institutionalized spouse lacks the ability to execute an assignment due to physical or mental impairment but the state has a right to bring a support proceeding against the community spouse without that assignment or 3. the state determines that the denial of eligibility would work an undue hardship.   Subsection j) Finally, Subsection j) indicates that the Department may pursue any available legal process to enforce its right of assignment to support against the community spouse or any other responsible party pursuant to section 120.319. These procedures may include, but are not limited to, the administrative support procedures set forth under Illinois 89 Illinois admin code section 103. Section 120.380 – Resources. Subsection a) This Section indicates that unless otherwise provided that the term “resource” as defined in 42 USC 1382b, (except subsection (a)(1) of that section, which excludes the home as a resource) means cash or any other personal or real property that a person owns and has the right, authority or power to liquidate. The global nature of this Section is reminiscent of Section 61 of the Internal Revenue Code wherein Congress sought to describe gross income. No doubt here the state is trying to be as expansive as possible in the definition of resources. Subsection b) Subsection b indicates that a resource is considered available to pay for the person’s own care when at the disposal of that person; when the person has a legal interest in the liquidated sum and has the legal ability to make the sum available for support, maintenance or medical care; or when the person has the lawful power to make the resource available or to cause the resource to be made available. Subsection c) This Section indicates that the value of non-exempt resources shall be considered in determining eligibility for any means-tested public benefit program administered by HFS, the Department of Human Services, or the Department of Aging. Subsection d) Subsection d is entitled determination of resources. This subsection is divided into three sub paragraphs: 1. The first paragraph provides that in determining financial eligibility for medical assistance, the Department will consider non-exempt and verified resources available to a person as of the date of decision on the application for medical assistance. The date of verification is referred to in Section 120.308(f), and may be prior to the date of decision.  Resources applied to a spend down obligation in a retroactive month shall not be treated as available in the determination of financial eligibility. Importantly, money considered as income for a month is not considered a resource for that same month. If income for a month is added to a bank account that month, the Department will subtract the amount of income from the bank balance to determine the resource level. Any income remaining in the following month is considered a resource. 2. The second subparagraph provides that in determining financial eligibility for a retroactive month, the Department will consider the amount of income and resources available to a person as of the first day of each month of the backdated months for which eligibility is sought. A new provision provides that resources spent prior to the end of the month of application to purchase a prepaid funeral burial contract, to pay for incurred medical expenses, or to pay legal fees up to $10,000 incurred in the month of application or in any of the three months prior to the month of application that are related to the eligibility application for long-term care insisted assistance shall not be considered available. 3. The third subparagraph provides that in determining a person’s spend down obligation  (see Section 120.384), the Department considers the amount of non-exempt resources available as of the date of decision in the case of initial eligibility, and the first day of the month, in the case of retroactive eligibility, that are in excess of the applicable resource disregard. Subsection e) This Section provides that the entire equity value of jointly held resources shall be considered available in determining a person’s eligibility for this assistance unless:
  1.  the resource is a joint income tax refund, 
  2. when one party documents that he or she does not have access ro the resource,
  3. jointly held accounts, and other related accessibility issue situations.
Subsection f) This Section deals with determining the eligibility of a person for long-term care services whosespouse resides in the community. It indicates that all non-exempt resources owned by the institutionalized spouse, the community spouse, or both shall be considered available to the institutionalized spouse in determining his or her eligibility for medical assistance. From the total amount of such resources may be deducted the CSRA, fo example $109,560. Subsection g) This Section provides that the treatment of certain trusts established prior to August 11, 1993, shall be treated as described in section 120.346. Subsection h) This Section provides that the treatment of trusts established after August 11, 1993, shall be treated in a manner described in section 120.347 Subsection i) Subsection i describes the treatment of life estates and indicates that the value of a life estate will be determined at the time the life estate in the properties established and at the time the property is liquidated. The section goes on to describe the value of life estates.  The section also refers to the value of the remainder interest and how values for these components can be determined by looking at tables located in Section 120. Table A . Subsection j) This Section indicates that the value of a person’s entrance fee into a continuing care retirement community shall be considered an available resource to the extent the person has the ability to use the entrance fee to pay for care, the person is eligible for refund when they die or terminates the community care contract and leaves the community, and if the entrance fee does not confer anownership interest in the continuing care community. Subsection k) This Section provides that non-homestead real property (including homestead property that is no longer exempt pursuant to Section 120.381(a)(1)) is considered an available resource unless:
  1. the property is exempted as income producing to the extent permitted under Section 120.381(a)(3) (limiting equity to $6,000); however the $6,000 equity limitation shall not apply to farmland property and personal property used in the income-producing operations related to farmland;
  2. ownership of property consists of a fractional interest of such a small value is substantial loss to the person would occur if the property were sold,
  3. the property has been listed for sale, in which case the property will not be counted is available for at least six months as long as the person makes a continued good effort to sell the property; or
  4. the homestead property that is no longer exempt is producing annual net income for the person an amount that is not less than 6% of the person’s net income. In making this calculation, the Department will recognize business expenses allowed for federal income tax purposes.
Section 120.381 – Exempt Resources Subsection a) This Section lists the exempt resources n determining eligibility for medical assistance:
  1. homestead property;
  2. personal effects and household goods;
  3. resources (for example, land, buildings, equipment and supplies or tools) necessary for self-support up to $6,000 of the person’s equity in the income-producing property, provided the property produces a net annual income of at least 6% of the excluded equity of the value of the property;
  4. automobile;
  5. life insurance policies of the total face value of $1,500 or less and all term life insurance policies. If the total face value exceeds $1,500 the cash surrender value must be counted as a resource
  6. a description of equity value is provided.
Subsection b) This Section describes the treatment of burial spaces, prepaid funerals /burial contracts, and other funds that are set aside for burial expenses and a whole list of other specialized exempt resources and assets based on public policy initiatives such as certain disaster relief and payments made to our Armed Forces. Subsection c) Describes the treatments of one’s  monies that are set aside for burial expenses. Subsection d) Deals with prepaid/burial contracts. Subsections e) through p) Deal with the treatment of other very specialized resources. Section 120.382 – Resource Disregard In this section the rule sets out the exempt resources that, in addition to those listed in Section 120.381, the cash value of certain resources shall be disregarded for AABD MANG cases: Subsection a) This Section provides $2,000 for a person, and $3,000 for a person and one dependent residing together. Subsection b) Provides $50 free to each additional dependent residing in the same household. Subsection c) Indicates that special provisions are made for the determination of resources on behalf of a person under a qualified long-term care insurance policy. Subsection d) Provides that eligibility for medical assistance or for the benefits described in Sections 120.72 and 120.73 does not exist when non-exempt resources exceed allowable disregards. Subsection e) Deals with qualified Medicare beneficiaries.  Section 120.384 – Spend down of Resources This Section provides that in determining a person’s resource spend down obligation, the Department will compare the non-exempt resources available to the person to the appropriate asset resource disregard.  The amount of resources in excess of the disregard determines the amount of the spend down. The Section then goes on to describe how spend down is met. Subsection a) Provides that if a person presents verification that excess resources are no longer available, the Department will make the appropriate changes the month following the month the person dispose of the resources. Subsection b) Provides that persons enrolled in spend down are not eligible for payment of covered medical services until spend down is met. A resource spend down is met by presenting allowable medical bills or receipts to the Department they will be amount of the person’s non-exempt excess resources. Subsection c) Provides that once excess resources have been used to meet spend down, whether or not the excess amount has actually been reduced, they are no longer considered. However, at reapplication/redetermination the Department will consider any excess non-exempt resources remaining as currently available.           
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Does Alzheimer’s disease ever bring positive personality changes?

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February 27, 2012

- Alzheimer's Care, Blog, Elder Law Articles

Yes, it can — but probably not the way you think, or may be hoping for. What Alzheimer’s can do is essentially erase bad behaviors or attitudes, which fall by the wayside as memory and decision-making abilities fade. When something like alcoholism, bipolar disorder or schizophrenia is present before the onset of Alzheimer’s, it “goes away” as the disease progresses. This has led some people who have loved ones with Alzheimer’s to say dementia or Alzheimer’s has “blessed” the person. If the victim was abusive or harsh beforehand, he or she might become happy, loving and docile afterward. Sometimes the families can joke about having a support group for people who are happy about Alzheimer’s. One man had an alcoholic wife for most of their 50 years together. This included the rearing of six children. As Alzheimer’s symptoms started to take more and more control of her mind, she forgot to drink and became more loving and soft-spoken. It was as if the dementia had brought out the best of her. She showed sides of herself that close friends and relatives had not seen in many years. Her children liked visiting, and she was kind to them. She also showed a good sense of humor. Often, her husband said those years were some of the happiest times of their married lives. In some ways, he was grateful for the dementia that claimed his wife’s mind. He went as far as to suggest that the disease had given him and his wife a second chance to live together happily. She stayed in their home, and he was her primary caregiver until her death. Alzheimer’s is a tragic disease, but sometimes it brings blessings.  For more information, check out our Indispensable Alzheimer’s Resource Guide which is available FREE online by clicking here
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Does medication cause the confusion and unsteadiness found with Alzheimer’s or are they just part of the disease’s progression?

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February 23, 2012

- Alzheimer's Care, Blog, Elder Law Articles

The short answer is both the disease’s progression and medication can be responsible for confusion and/or unsteadiness in Alzheimer’s patients. Since Alzheimer’s is a neurological disorder, it causes confusion; it also can affect a person’s ability to move around, or ambulate. Alzheimer’s effects on the brain can cause a person to have difficulty with perception, which in turn can affect how a person walks. Black strips in carpeting may appear to be an opening in the floor or something else that needs to be stepped over. A shiny floor might give the impression it’s wet. Perceptions like these understandably can cause unsteadiness. Unfortunately, medicines’ side effects also can cause unsteadiness or confusion. That’s why family members and close friends are so important. As firsthand observers of a person’s behavior, they can notice changes easier than others. It is particularly important to watch for side effects right after a new medication or dosage has been introduced. Any sudden change in behavior most likely will be due to medication because Alzheimer’s typically does not progress quickly enough to create such changes. Ask your pharmacist or visit the website of a specific medication (e.g. www.namenda.com) to learn about possible side effects. These websites have a lot of useful information. Keep in mind that there also could be physical difficulties that arise that have nothing to do with the Alzheimer’s or any medication. Difficulty walking or any sudden confusion could be caused by an infection or another source of pain. Careful observation followed by some “detective” work will help discern what’s going on. It’s not uncommon for this to become second nature. You might not even realize you’re taking these steps after a while. Always remember, though, that if you have investigated and tried various options and nothing seems to work, symptoms such as confusion or unsteadiness could just be part of the disease’s natural, unrelenting progress. To help cope with caring for someone with Alzheimer’s, you might want to obtain a copy of this free resource, The Indispensable Alzheimer’s Resource Kit.    
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Having heard a lot about agitation, I’d like any extra advice I can get

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February 22, 2012

- Alzheimer's Care, Blog, Elder Law Articles

“Love cures people. Both the ones who give it and the ones who receive it.” 

— Karl Menninger

The above is a good quote to keep in mind. Dealing with agitation and/or dementia can be a marathon struggle. Choose your battles wisely and know that just because a person’s behavior might be bothersome to you, that does not mean it is an issue for a person with dementia. If you’re stressed about a loved one’s behavior, first ask yourself: Is this person in danger? Is anything detrimental to his or her health? Do I really have to do anything? Or might I be making a mountain out of a molehill? Here’s a good example: Your loved one is getting dressed — with multiple layers of clothing. This is a change from pre-dementia days. Before worrying, getting angry or trying to change anything, ask yourself: “Is it really hurting anyone?” If the answer is “no,” then let it go. Confronting someone with dementia about this and making him or her change clothes, could produce agitation, and possibly an angry outburst. Remember: Your goal in this type of situation is to prevent or divert any stimulus that could bring on agitation. As typical adults, we don’t like being told what to do. A person with dementia is no different in this regard. Being able to “go with the flow” on your part will go a long way; concentrate more on the issues that are truly serious enough to address. If you can do this, you and your loved one’s lives will be much less stressful. We must constantly remember an underlying premise: People with dementia always need to feel loved, useful and needed. We must help create an environment that shows them love. We also must allow them to help as much as they want, and in so doing set them up for success. A big tenet of this is coming to grips with “behavior acceptance.” As caregivers and loved ones, we have to realize unwanted behavior is part of the disease process and that there is a reason for it. When we think this way, we can respond more effectively to situations where agitation is present, as well as others that need attention. What are some strategies for doing this? For example, instead of putting someone on the defensive with something like: “Your clothes are dirty. Would you please change into something clean?” You could phrase it this way: “Let’s go change our clothes so we an go to the store.” This directs action but it is less demanding of the person with dementia. By involving yourself, it comes off as less threatening. Use this line of thought, if it will help: “We cannot control what comes our way, but we can control how we respond.” If our thought preparation is, “How can I best respond to this situation or behavior?” it averts putting the onus on your loved one as “the problem.” The person with dementia is not able to change, so we have to.
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What can I do to my mother’s environment to lessen her agitation?

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February 21, 2012

- Alzheimer's Care, Blog, Elder Law Articles

Human behavior is greatly affected by one’s environment. Therefore, you must pay special notice to what goes on in the surroundings of a person who has dementia. That person is liable to have heightened chances of feeling fear or insecurity so he or she needs to feel safe to minimize them. Because there are so many environmental aspects that can cause worsened confusion or agitation, a continual assessment of the overall environment can help prevent agitation. A few examples of potential trouble areas include:
  • Temperature (too hot or too cold)
  • Noise (too loud or too much
  • Lighting (too bright or too dim)
  • Walkways/hallways (too cluttered)
  • People (whether they’re comfortable around them)
Look for patterns associated with typical sources of agitation, including: bathing, activities or events such as children visiting, and time of day. Address the specific issue as soon as you denote a pattern. It might mean changing visiting or showering times. While these issues might seem relatively insignificant to you or most people, they can be a HUGE issue to your loved one. Therefore, try to set up environments that are laid back and can help ease agitation. What is best? Whatever works for your loved one. Some examples of calming effects are:
  • Playing a favorite kind of video or music
  • Sititng in front of a fireplace
  • White noise, such as a fan or other motor hum
  • Getting fresh outside air
  • Burning fragrant candles or incense
  • Bird watching
  • Anything else that is known to decrease agitation for your loved one
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Are you thinking of buying into a comfortable retirement community?

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February 20, 2012

- Blog, Elder Law Articles, Medicaid and Paying for Nursing Home Care

 

Are you thinking of buying into a comfortable retirement community?

——————————-

That is often a good idea but, think again carefully.

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The new Illinois Medicaid law taking effect on January 1, 2012 dramatically change the treatment of entrance fees at Continuing Care Retirement Communities

Continuing Care Retirement Communities (CCRCs) are communities that provide a full continuum of care for its residents.  They have flexible accommodations designed to meet their resident’s health and housing needs as their needs change over time. They offer independent living, assisted living and nursing home care, usually all in one location.  As a requirement for admission to most CCRCs, residents are required to pay an entrance fee or a lump sum “buy-in” which, in addition to other things, guarantees the resident’s right to live in the facility for the remainder of their lifetime.  In addition to the entrance fee, residents also pay a monthly service fee. The entrance fee is often, but not always, reimbursable (at least partially) if the individual moves from the facility, if they pass away while a resident at the facility, or if they otherwise terminate the contract.  Many contracts also contain a provision wherein an individual is able to use a portion of their entrance fee toward their monthly resident charges if the resident exhausts his resources and becomes otherwise unable to pay. PRIOR LAW Prior to the new Medicaid law (the Deficit Reduction Act of 2005, hereinafter “DRA”), the entrance fee was generally not considered an available asset for Medicaid eligibility purposes. NEW  LAW Under the new DRA, that took effect on January 1, 2012, a CCRC entrance fee is considered an available or “countable” asset if: (1) the contract provides the entrance fee may be used to pay for care should the resident run out of money and become unable to pay their monthly charge; or (2) the individual is eligible for a refund of any remaining entrance fee when the individual dies, leaves the community or otherwise terminates the life care contract; and (3) the entrance fee does not confer an ownership interest in the CCRC. Also, under the new law, CCRC’s are given the authority to include in their contacts a provision which requires residents to spend all of their resources on their care prior to applying for Medicaid benefits (essentially disallowing any Medicaid planning or asset protection once the contract is signed). Thus,   when an individual applies for admission to a CCRC, the application may request full disclosure of an individual’s resources. Prior to the new law, regardless of the amount of resources an individual declared, the CCRC could not prohibit the individual from doing any long-term care planning or asset protection planning and then applying for Medicaid. PROBLEM CREATED BY NEW LAW Now CCRC’s can contractually require a resident to spend down all of the assets they declared at the time of admission before applying for medical assistance. This new provision will greatly limit the ability of CCRC residents to protect their assets once admitted to the community.  Some residents may not care about the ability to protect their assets once they are admitted to the community. But for those of you that do care about protecting assets from being lost to the devastating cost of long-term care, the inability to plan with your remaining dwindling resources is a big deal! CONCLUSION It is a good idea to consult with an experienced elder law attorney prior to entering into a contract at a Continuing Care Retirement Community. This ensures that you understand how your entrance fee/”buy-in” agreement may financially and legally impact your  long term care plan and any asset protection planning that you may have in mind. CCRC’s can do a nice job of providing care, but there is no substitute for getting the appropriate legal advice before you enter into a binding contract with anyone.
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What are the effects of pain on agitation?

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February 17, 2012

- Alzheimer's Care, Blog, Elder Law Articles

Confusion and/or agitation almost always increase when pain is present. Furthermore, if there’s a sudden increase in confusion or agitation, it should be a tip-off that something wrong is going on physically. Dementia does not typically progress that rapidly. There is a cycle of pain that gives us a picture of how pain can affect the entire body. It goes something like this: Pain, anxiety, fatigue, depression, pain, anxiety, fatigue, depression, pain … and so on. If a person who has dementia is in this cycle and unable to let anyone know, we have to intercede and determine what’s really happening. The sources of pain can be numerous. Most people forget at least a few when listing them. A partial list includes: arthritis (the No. 1 affliction of older Americans), joint and muscle problems, infection, inflammation and headaches. If your loved one has chronic problems or even just a history with any of these conditions, ongoing visits with the physician (who presumably will prescribe some form of treatment) are critical. Ongoing assessments by a doctor or other clinician are very important. By examining overall health frequently, a clinician can learn whether something like a headache, urinary tract infection or other condition is a sign of something bigger. Be sure to keep the physician informed, even when you’re not going to see him or her in person. Watch your loved one’s facial expressions and body language since they are common indicators. Something as simple as a flare-up of arthritis or a foot wore can cause a change in behavior. Also be aware that some medications can cause agitation. Always call a physician if you have any questions or concerns about medication issues or effects. Caregiving involves ever moving targets so constant assessments and questions should be a part of it. Talking with others in your position can help. Discussions with other caregivers, whether they’re in a support group you’ve joined or are on their own, can be a good source of support. Family members and friends who sincerely care and try to understand are other good resources. There is no need to think you have to go through these challenges alone. Reach out for, and accept, help often. There are many good sources out there, including this free booklet: “The Indispensable Alzheimer’s Resource Kit.” Click here to get it sent to you for free.  
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Sometimes words don’t seem like enough when trying to communicate with someone with dementia

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February 16, 2012

- Alzheimer's Care, Blog, Elder Law Articles

Nonverbal communication is important, more so perhaps with someone who has Alzheimer’s or dementia than with others. That goes for communication in both directions: from you and to you. Body language can be responsible for up to 80% of all communication. It is very important therefore, when communicating with our loved ones to do more than just get the “right” words. Facial expression and tone of voice are a big part of your message. Alzheimer’s patients are still sensitive to people around them and can be rather intuitive. They know when someone is not being sincere. Similarly, they can be very aware if they’re being excluded from something or being talked down to. People with Alzheimer’s can sometimes look into your eyes and seem to read your soul — like a “sixth sense.” Be aware of the body language they may be sending your way. Bouncing up from a chair and pacing around could indicate, for example, that a visit to the restroom is warranted. Or it could be an indicator of some type of pain or discomfort. Always keep in mind that pain could be a part of the equation. As for calming your loved one’s agitation or anxiety, sometimes less is more — as in talking less, or not at all. Sometimes you don’t need to say anything. Touch is an important part of the human condition, so resort to hugs and gentle touches on the hand, arm or shoulder often, if you can. A simple hug can dramatically change a person’s mood instantly. Sometimes, an angry caregiver might not want to give a hug, but that’s the time when your loved one might need it most. Embrace her, and the opportunity to improve one’s existence. It might be stepping out of your comfort zone, but the results could amaze you. A hug can release tension immediately (in your loved one and you). A gentle massage or back run also can soothe the mood and have a relaxing effect. For more information, download the Indispensable Alzheimer’s Resource Kit which can be obtained at no cost by clicking here     
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How can I minimize my loved one’s agitation while trying to communicate with her?

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February 15, 2012

- Alzheimer's Care, Blog, Elder Law Articles

An important part of any type or relationship is communication. An often tough task becomes increasingly difficult, however, when a person with dementia is involved. Both processing and expressing information become more difficult, which can lead to frustration, which can ultimately manifest itself as agitation. Anything from mere pacing to lashing out can be a sign of agitation. As a caregiver, you want to avert agitation as much as possible. Effective communication can help. Below is a list of ways to improve communication. It is by no means complete, but if you follow these tenets, you’ll be doing well:
  •  Talk with a calm presence
  • Don’t argue — you’ll never win
  • Validate feelings
  • Smile and be pleasant
  • Approach from the front so you don’t startle your love one
  • Identify yourself, if needed
  • Maintain eye contact
  • Ask one question at a time
  • Go slowly. Remember that hurrying heightens frustration
  • Use short sentences
  • Give plenty of time to respond
  • Repeat information as needed. Repetition is good and usually helpful
  • Use touch, such as on the shoulder, knee, back or hand
  • Give hugs — many times a day
  • Laugh together
  • A high-pitched voice might convey that you are upset so speak with a lower tone when possible
  • Speak clearly and directly (and, to repeat, slowly)
  • Don’t correct your loved one
  • Ask things nicely: Don’t make demands
  • If you feel your words becoming heated, stop. Take a deep breath. Try again later
  • Don’t take adverse behavior personally.
  • Respect the person as an adult; don’t talk down to him or her
  • If he or she cannot find or make the words, gently finish a sentence as needed.
  • When at all possible, allow choices — such as “Should we pay the gas bill or electric bill first?” or “Would you like tea or coffee?” etc.
  • Frequently praise your loved one and spread affirmation — for even the smallest things. Make phrases like these a frequent part of your vocabulary: “Thank you,” “Good job!” and “You’re the best!”
For more information, be sure to downloard the Indispensable Alzheimer’s Resource Kit which is available at no cost to you simply by clicking here.
       
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