What we’re expecting in 2021, and beyond…

From telehealth to digital trials, customer engagement to healthcare data, Healthware Group outlines the key trends that are expected to shake up digital health this year.

Well, it goes without saying, COVID-19 has resulted in a rapid adoption of digital technologies across all industries, most notably in healthcare. There are several important aspects to these shifts for pharma, biotech and medical device companies, so what can we expect to see over the next 12 months and beyond?

Telehealth keeps maturing and integrates into care pathways

The adoption of telehealth, which was already accelerating pre-pandemic, has been exponentially driven by COVID-19. It’s swept aside several historic barriers to uptake, such as the healthcare professional and patient desire to physically meet, medical guidelines that focus on in-person diagnosis and reimbursement models that discourage remote consultation.

2020 was a psychological and systemic tipping point for telehealth, adoption of which will accelerate in 2021 as it becomes the norm, in the process driving new self-service approaches to medicine and participation-based reimbursement models.

Mental health worsens – digital tools continue to fill the gap

The emotional and psychological wellbeing of the world’s population has been put under tremendous strain because of the COVID-19 pandemic, exacerbating an existing global mental health epidemic.

There is an opportunity to address this at scale with digital tools and techniques, and expand support into just about any therapeutic area through the holistic integration of mental and behavioural health solutions that improve patient care.

Mental health support is key to improving outcomes in chronic diseases and can also provide an invaluable empathetic and psychological component of support for people dealing with other complex medical situations.

When coupled with conversational interfaces and AI, digital mental health solutions are perceived as highly personal by users and open the door for a profound transformation in people’s relationships with digital health tools and how they integrate them into their daily lives.

Clinical trials get more and more digitalised

As study enrolment continues to lag drastically behind target, patient recruitment is set to rely even more on digital marketing to improve its speed and accuracy. These techniques will also need to be applied to screening, interviews and the actual studies themselves, particularly as more trials move towards a virtual, decentralised or hybrid model.

Digital screening of subjects makes their geographical location less relevant, which may make studies more attractive as there is less requirement to travel. And with the support of remote sampling, and growing tools for gathering real world evidence about improved quality of life, the clinical trials of the future can be done faster, with lower costs and on a more decentralised basis.

‘Aging in place’ becomes more commonplace

Aging in place will become more common as the baby boomer generation ages and feels more comfortable leveraging tools like remote monitoring, telehealth and disease management platforms. Living independently will be critical to this age group and digital health tools will be critical in supporting them in this endeavour. The adoption and growth of digital tools is expected to explode as a result. This is certainly evident in the amount of investment in the category.

The inevitable invisibility of digital health

Technology will begin to dematerialise, as has already been seen in other industries, and digital health will increasingly be woven into everyday objects. We’re starting to see this happen through the emergence of smart homes and smart cars (i.e., steering wheels that also measure the driver’s heart rate). As more data is collected passively, there will be more opportunities for integration.

No more ‘business as usual’ for pharma’s customer engagement

Life sciences companies need to rethink their customer engagement paradigms in light of changing customer preferences. Pharma should update the role of the rep from simply delivering a sales message to more of a concierge service model, providing access to – and facilitating the delivery of – meaningful content that physicians want and need. As such, reps will need to be reskilled.

Self-service models for HCPs are also needed in order to provide access to content when and how they want it – as already seen in other industries, the expectation will be for 24/7 access.

While digital-only product promotion was laughed at just a year ago, we’ve already seen the first digital-only blockbuster launch, and we expect this will become a growing trend. Pharma companies will need to continually rethink what works and not be afraid to experiment with solutions they’ve never tried before.

A growing need for digital health proficiency

While 2014 is often quoted as the first year where the majority of working healthcare professionals were digital natives, 2020 was the year when the remaining digital immigrants were forced to travel into the online world. Post-pandemic, online engagement will continue to be commonplace and 2021 will see much broader rollouts of ‘digital’ training for medics (young and old), and all medical societies will have to embrace online learning and digital publishing models. In addition, the subject matter for ongoing disease research will focus even further on COVID-19 comorbidities and the longer-term impact of the virus.

Integration of telehealth strategy into commercial models

Amazon is making a serious global move into healthcare delivery with the acquisition of PillPack, and its recent launch of Amazon Pharmacy. With Amazon Care, it is starting to experiment with virtual health care services, offering them first to its own employees and with plans to expand them to health plans and other employers.

These moves are bringing Amazon closer and closer to a true end-to-end model, similar to the turnkey solutions offered by the likes of Hims, Ro and others in the category with an original focus on conditions with an associated stigma. We’re already starting to see some pharma build end-to-end solutions like this in birth control, and we’re expecting to see these efforts branch out into other disease areas. And beyond building end-to-end solutions like this to drive scripts, we expect pharma to begin approaching telehealth more generally as a potential marketing/sales channel, helping to remove barriers to care, improving online visits and even helping HCPs understand the benefits.

Consolidation of digital health platforms

Digital health platforms will likely see a wave of further consolidations, with a few leading platforms starting to stake out their respective positions across the healthcare spectrum. This trend can be seen as a net positive, in that it will enable digital therapeutic solution developers to concentrate on building the individual vertical products that will live on these platforms.

However, issues around data ownership and sharing will need to be addressed and resolved (by way of regulations) to avoid a situation where solutions that are competitive to platform owners’ own cannot find a way to be listed on them. Price controls will also need to be mandated to avoid the types of ‘access taxes’ currently seen, such as with Apple’s App Store fees on sales charged to app developers (upwards of 30% of sales collected), who have no way to sell their apps directly to iPhone users.

Services to manage and make sense of the health data explosion

We expect to see what we call Health Data as a Service (HDaS). As more solutions and devices generate increasing amounts of health data, there is a greater need to aggregate that data in a useful way for consumers. Consumers want and need tools to make sense of all that data. They also want to ensure they know who has access to that data, and control over where it can flow. So, we expect to see more tools supporting consumers in this way.

We look forward to continuing to contribute to the advancement of digital health and digital transformation across all aspects of the healthcare ecosystem and welcome your thoughts on the above.

About the authors

Roberto Ascione is Healthware Group’s CEO and founder, and a pioneer in digital health and a recognised thought leader, people-inspiring founder, serial entrepreneur and global manager.

 

Gerry Chillè is senior partner at Healthware Group, in charge of its digital therapeutics pipeline strategy and development.

 

Fulvio Fortini is Healthware’s managing director – Italy. With more than 20 years of experience, he is passionate about digital technology and an expert in the health and wellness sector.

 

Petteri Kolehmainen is managing director – Finland, leading Healthware’s Helsinki team, with focus the Nordic and Baltic countries, bringing strong experience in technology and business development.

 

Kristin Milburn is managing director at Healthware Labs, which was launched in New York in 2015 with a mission to accelerate digital health and therapeutic innovation.

 

Ariel Salmang is managing director at Intouch International, a unique joint venture between Healthware Group and the Intouch Group.

 

Paul Tunnah is Healthware’s chief content officer and managing director UK, and a recognised author, speaker and industry advisor with a passion for helping organisations tell authentic stories.

 

If you’d like to learn more about how we think please reach out to [email protected]

About Healthware Group

Healthware is a next-generation integrated consulting group. For more than 20 years it has been offering large companies and start-ups in the life sciences and insurance sectors a unique set of services and expertise in strategic consulting, communication, technology and innovation to drive the digital transformation of health.

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Covid Vaccine Rollout Leaves Most Older Adults Confused Where to Get Shots

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Over a month into a massive vaccination program, most older Americans report they don’t know where or when they can get inoculated for covid-19, according to a poll released Friday.

Nearly 6 in 10 people 65 and older who have not yet gotten a shot said they don’t have enough information about how to get vaccinated, according to the KFF survey. (KHN is an editorially independent program of KFF.)

Older Americans are not the only ones in the dark about  the inoculation process. About 55% of essential workers —designated by public health officials as being near the front of the line for vaccinations — also don’t know when they can get the shots, the survey found. Surprisingly, 21% of health workers said they are unsure about when they will get vaccinated.

Black and Hispanic adults, as well as those in low-income households, are among the groups struggling most to find vaccine information. Within each of those groups, at least two-thirds said they do not have enough information about when they can get vaccinated, the survey found.

The covid vaccines, which were first distributed in mid-December to health care workers and people living in nursing homes or assisted living centers, are now available for other older adults in most states, though age restrictions vary. Ohio, for example, opened up vaccinations to all residents  80 and older. In Virginia, the minimum age for the second wave of shots is 65. In Indiana, it’s 70; Maryland, 75. Some states, such as Florida and Texas, started vaccinating anyone 65 and up in December, though many states did not begin vaccinating all seniors until January.

Limited doses have left many seniors scrambling to get an inoculation appointment.

For example, at 9 a.m. Thursday, Washington, D.C., opened 2,200 covid vaccine appointment slots for people 65 and older in several hard-hit neighborhoods. Within 20 minutes, they were all filled.

To date, more than 15 million Americans have been vaccinated for covid, which has infected 24 million and killed more than 400,000. The two covid vaccines authorized for emergency use by the Food and Drug Administration require two doses either three or four weeks apart.

Despite the rocky rollout of vaccines, two-thirds of respondents were “optimistic” that things will get better.

Sixty-five percent of adults said they believe the distribution of the vaccines is being done fairly, but half of Black adults said they were concerned that the efforts are not adequately considering the needs of the Black community.

The KFF survey of 1,563 adults was conducted Jan. 11-18. The margin of sampling error is plus or minus 3 percentage points.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Vaccination Disarray Leaves Seniors Confused About When They Can Get a Shot

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For weeks, doctors’ phones have been ringing off the hook with anxious older patients on the other end of the line.

“When can I get a covid-19 vaccine?” these patients want to know. “And where?”

Frustration and confusion are rampant as states and counties begin to offer vaccines to all seniors after giving them first to front-line health care workers and nursing home residents — the groups initially given priority by state and federal authorities.

My 91-year-old mother-in-law, who lives in upstate New York, was one of those callers. She said her doctor’s office told her it could be several months before she can get her first shot.

That was before New York’s Gov. Andrew Cuomo announced on Friday that the state would begin offering vaccines to residents age 75 and older starting Monday. On Tuesday, the state changed vaccine policies again, this time making residents 65 and older eligible.

In this chaotic environment, with covid cases and deaths skyrocketing and distribution systems in a state of disarray, it’s difficult to get up-to-date, reliable information. Many older adults don’t know where to turn for help.

Since the holidays, I’ve heard from dozens of people frustrated by poorly informed staffers at physicians’ offices, difficult-to-navigate state and county websites, and burdensome or malfunctioning sign-up arrangements. Below are some questions they posed, with answers drawn from interviews with experts and other sources, that may prove helpful.

Keep in mind that states, counties and cities have varying policies, and this is a rapidly shifting landscape with many uncertainties. Foremost among them are questions regarding vaccine supply: how many doses will become available to states and when and how those will be allocated.

Q: How can I make an appointment to get a vaccine? — James Vanderhye, 77, Denver

Vanderhye is a throat cancer survivor who suffers from sarcoidosis of the lungs and heart — an inflammatory disease.

Colorado Gov. Jared Polis announced on Dec. 30 that residents 70 and older could start getting covid vaccines, but Vanderhye wasn’t sure whether he needed to sign up somewhere or whether he’d be contacted by his physicians — a common source of confusion.

UCHealth, the system where Vanderhye’s doctors practice, has created a registry of patients 70 and older and is randomly selecting them for appointments, Dr. Jean Kutner, its chief medical officer told me. It’s reaching out to patients through its electronic patient portal and is planning to notify those who don’t respond by phone down the line. Then, it’s up to patients to finalize arrangements.

Nearly 200,000 people 70 and older are patients at UCHealth’s hospitals and clinics in Colorado, Wyoming and Nebraska.

TIPS: Although some health systems such as UCHealth are contacting patients, don’t assume that will happen. In most cases, it appears, you will need to take the initiative.

Check with the physician’s office, hospital or medical clinic where you usually receive care. Many institutions (though not all) are posting information about covid vaccines on their websites. Some have set up phone lines.

Some health systems are willing to vaccinate anyone who signs up, not just their patients. Kaiser Permanente, which operates in California, Colorado, Georgia, Hawaii, Oregon, Washington, Washington, D.C., and parts of Virginia and Maryland, is among them, according to Dr. Craig Robbins, co-leader of its national covid vaccination program. (Within the next few weeks, it will post an online registration tool on plan websites.) Check with major hospitals or health systems in your area to see what they’re doing. (KHN is not affiliated with Kaiser Permanente.)

Most places are asking people to sign up online for appointments; some sites require multiple steps and their systems may seem hard to use. If you don’t have a computer or you aren’t comfortable using one, ask a younger family member, friend or neighbor for help. Similarly, ask for help if you aren’t fluent in English.

If you can’t figure out how to sign up online, call your local county health department, Area Agency on Aging or county department on aging and ask for assistance. Every state has a covid-19 hotline; see if the hotline can direct you to a call center that’s taking appointments. Be prepared for long waits; phone lines are jammed.

Q: My mother has stage 3 renal failure, high blood pressure and dementia. She’s unable to take care of herself or be left alone. When can I get her vaccinated with the COVID shot? — Wendy, 61, Chandler, Arizona

Wendy had checked Maricopa County’s website days before we talked on Jan. 5 and couldn’t figure out when her 84-year-old mother might get a vaccine appointment. The week before, her 90-year-old father died, alone, of renal failure complicated by pneumonia in a nursing home.

Three days after our conversation, Maricopa County announced that people 75 and older could start making appointments to be vaccinated on a “first-come, first-served” basis on Monday, Jan. 11. (The state’s appointment site is https://podvaccine.azdhs.gov/; callers should try 844-542-8201 or 211, according to information provided by the county.)

In Arizona, “it’s up to each county to come up and execute a plan for vaccine distribution,” said Dana Kennedy, state director of AARP Arizona.

Demand is high and vaccine supplies are limited, other places have found. For example, on Jan. 7, a 1,200-slot vaccine clinic in Oklahoma City for adults 65 and older filled up within four minutes, according to Molly Fleming, a public information officer at the Oklahoma City-County Health Department.

“Once we get more vaccine supplies coming more frequently, we will do more clinics,” Fleming said. “The challenge we have right now is, we need the vaccine and we don’t know when it’s coming in.”

TIPS: Consult AARP’s state-by-state covid vaccine guides, focused on older adults and updated daily. (To access, go to https://www.aarp.org/coronavirus/. In the right-hand column, click on “the vaccine in your state.”) More than 20 states are listed there now, but guides for all states should be available by the end of January.

Meanwhile, check local media and your county’s and state’s health department websites regularly for fresh information about covid vaccine distribution plans.

On Monday, for example, Washington, D.C., unveiled a new vaccination registration site for residents 65 and older and health care workers. The week before, Illinois announced it would extend vaccines to residents 65 and older when it moved into the next phase of its vaccination plan, and the city of Chicago followed suit. The timetable for those transitions remains unclear.

Be prepared to be patient as problems with distribution surface. States and counties around the country are learning from problems that have arisen in places such as Florida — crashed phone lines, long lines of older adults waiting outdoors, massive confusion. It may take some time, but vaccine rollouts should become smoother as more sites come online and supplies become more readily available.

Q: When can a 72-year-old male with chronic lymphocytic leukemia expect to be vaccinated at Kaiser Permanente in Southern California? — Barry

California last week announced that counties that have made significant progress and have adequate supplies can move toward offering vaccines to residents 75 and older.

How soon this will happen isn’t clear yet; it will vary by location. But even then, Barry wouldn’t qualify immediately since he’s only 72 and it could take several months for vaccines to become available to people in his age group (65 to 74), said Robbins, who’s helping lead Kaiser Permanente’s vaccination program.

Barry is at especially high risk of doing poorly if he develops covid because of the type of cancer he has — leukemia. But, for the most part, medical conditions are not being taken into account in the initial stages of vaccine distribution around the country.

An exception is the Mayo Clinic. It’s identifying patients at highest risk of getting severe infections, being hospitalized and dying from covid at the Mayo Clinic Health System, a network of physician practices, clinics and hospitals in Iowa, Minnesota and Wisconsin. When states allow older adults outside of long-term care institutions to start getting vaccines, it will offer them first to patients at highest risk, said Dr. Abinash Virk, co-chair for Mayo Clinic’s vaccine rollout.

TIPS: Even if vaccines aren’t available right away, production is increasing, new products are in the pipeline, and new ways of distributing vaccines — notably mass distribution sites — are being planned. If you have to wait several weeks or months, don’t give up. Persistence is worth the effort, given the vaccine’s benefits.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Are You Old Enough to Get Vaccinated? In Tennessee, They’re Using the Honor System

In December, all states began vaccinating only health care workers and residents and staffers of nursing homes in the “phase 1A” priority group. But, since the new year began, some states have also started giving shots to — or booking appointments for — other categories of seniors and essential workers.

As states widen eligibility requirements for who can get a covid-19 vaccine, health officials are often taking people’s word that they qualify, thereby prioritizing efficiency over strict adherence to distribution plans.


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“We are doing everything possible to vaccinate only those ‘in phase,’ but we won’t turn away someone who has scheduled their vaccine appointment and tells us that they are in phase if they do not have proof or ID,” said Bill Christian, spokesperson for the Tennessee Department of Health.

Among the states pivoting to vaccinating all seniors, timelines and strategies vary. Tennessee started offering shots to people 75 and older on Jan. 1. So, Frank Bargatze of Murfreesboro, Tennessee, snagged an appointment online for his father — and then went ahead and put his own name in, though he’s only 63.

“He’s 88,” Bargatze said, pointing to his father in the passenger seat after they both received their initial shots at a drive-thru vaccination site in Murfreesboro, a large city outside Nashville. “I jumped on his bandwagon,” he added with a laugh. “I’m going to blame it on him.”

Bargatze does work a few days a week with people in recovery from addiction, he added, so in a way, he might qualify as a health care worker.

Some departments are trying more than others, but overwhelmed public health departments don’t have time to do much vetting.

Dr. Lorraine MacDonald is the medical examiner in Rutherford County, Tennessee, where she’s been staffing the vaccination site. If people seeking the vaccine make it through the sign-up process online, MacDonald said, and show up for their appointment, health officials are not going to ask any more questions — as long as they’re on the list from the online sign-up.

“That’s a difficult one,” MacDonald acknowledged, when asked about people just under the age cutoff joining with older family members and putting themselves down for a dose, too. “It’s pretty much the honor system.”

People getting vaccinated in several Tennessee counties told a reporter they did not have to show ID or proof of qualifying employment when they arrived at a vaccination site. Tennessee’s health departments are generally erring on the side of simply giving the shot, even if the person is not a local resident or is not in the country legally.

The loose enforcement of the distribution phases extends to other parts of the country, including Los Angeles. In response, New York’s governor is considering making line-skipping a punishable offense.

Still, many people who don’t qualify on paper believe they might need the vaccine as much as those who do qualify in the initial phases.

Gayle Boyd of Murfreesboro is 74, meaning she didn’t quite make the cutoff in Tennessee, which is 75. But she’s also in remission from lung cancer, and so eager to get the vaccine and start getting back to a more normal life, that she joined her slightly older husband at the Murfreesboro vaccination site this week.

“Nobody’s really challenged me on it,” she said, noting she made sure to tell vaccination staffers about her medical issues. “Everybody’s been exceptionally nice.”

Technically, in the state’s current vaccine plan, having a respiratory risk factor like lung cancer doesn’t leapfrog anyone who doesn’t otherwise qualify. But in some neighboring states such as Georgia, where the minimum age limit is 65, Boyd would qualify.

Even for those who sympathize with such situations, anecdotes about line-skipping enrage many trying to wait their turn.

“We try to be responsible,” said 57-year-old Gina Kay Reid of Eagleville, Tennessee.

Reid was also at the Murfreesboro vaccination site, sitting in the back seat as she accompanied her older husband and her mother. She said she didn’t think about trying to join them in getting their first doses of vaccine. “If you take one and don’t necessarily need it, you’re knocking out somebody else that is in that higher-risk group.”

But there is a way for younger, healthier people to get the vaccine sooner than later — and not take a dose away from anyone more deserving.

A growing number of jurisdictions are realizing they have leftover doses at the end of every day. And the shots can’t be stored overnight once they’re thawed. So some pharmacists, such as some in Washington, D.C., are offering them to anyone nearby.

Jackson, Tennesse, has established a “rapid response” list for anyone willing to make it down to the health department within 30 minutes. Dr. Lisa Piercey, the state’s health commissioner, said her own aunt and uncle received a call at 8 p.m. and rushed to the county vaccination site to get their doses.

Piercey called it a “best practice” that she hopes other jurisdictions will adopt, offering a way for people eager for the vaccine to get it, while also helping states avoid wasting precious doses.

This story is part of a partnership that include WPLN, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Seniors Face Crushing Drug Costs as Congress Stalls on Capping Medicare Out-Of-Pockets


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Sharon Clark is able to get her life-sustaining cancer drug, Pomalyst — priced at more than $18,000 for a 28-day supply — only because of the generosity of patient assistance foundations.

Clark, 57, a former insurance agent who lives in Bixby, Oklahoma, had to stop working in 2015 and go on Social Security disability and Medicare after being diagnosed with multiple myeloma, a blood cancer. Without the foundation grants, mostly financed by the drugmakers, she couldn’t afford the nearly $1,000 a month it would cost her for the drug, since her Medicare Part D drug plan requires her to pay 5% of the list price.

Every year, however, Clark has to find new grants to cover her expensive cancer drug.

“It’s shameful that people should have to scramble to find funding for medical care,” she said. “I count my blessings, because other patients have stories that are a lot worse than mine.”

Many Americans with cancer or other serious medical conditions face similar prescription drug ordeals. It’s often worse, however, for Medicare patients. Unlike private health insurance, Part D drug plans have no cap on patients’ 5% coinsurance costs once they hit $6,550 in drug spending this year (rising from $6,350 in 2020), except for very low-income beneficiaries.

President-elect Joe Biden favors a cap, and Democrats and Republicans in Congress have proposed annual limits ranging from $2,000 to $3,100. But there’s disagreement about how to pay for that cost cap. Drug companies and insurers, which support the concept, want someone else to bear the financial burden.

That forces patients to rely on the financial assistance programs. These arrangements, however, do nothing to reduce prices. In fact, they help drive up America’s uniquely high drug spending by encouraging doctors and patients to use the priciest medications when cheaper alternatives may be available.

Growing Expense of Specialty, Cancer Medicines

Nearly 70% of seniors want Congress to pass an annual limit on out-of-pocket drug spending for Medicare beneficiaries, according to a KFF survey in 2019. (KHN is an editorially independent program of KFF.)

The affordability problem is worsened by soaring list prices for many specialty drugs used to treat cancer and other serious diseases. The out-of-pocket cost for Medicare and private insurance patients is often set as a percentage of the list price, as opposed to the lower rate negotiated by insurers.

For instance, prices for 54 orally administered cancer drugs shot up 40% from 2010 to 2018, averaging $167,904 for one year of treatment, according to a 2019 JAMA study. Bristol Myers Squibb, the manufacturer of Clark’s drug, Pomalyst, has raised the price 75% since it was approved in 2013, to about $237,000 a year. The company believes “pricing should be put in the context of the value, or benefit, the medicine delivers to patients, health care systems and society overall,” a spokesperson for Bristol Myers Squibb said via email.

As a result of rising prices, 1 million of the 46.5 million Part D drug plan enrollees spend above the program’s catastrophic coverage threshold and face $3,200 in average annual out-of-pocket costs, according to KFF. The hit is particularly heavy on cancer patients. In 2019, Part D enrollees’ average out-of-pocket cost for 11 orally administered cancer drugs was $10,470, according to the JAMA study.

The median annual income for Medicare beneficiaries is $26,000.

Medicare patients face modest out-of-pocket costs if their drugs are administered in the hospital or a doctor’s office and they have a Medigap or Medicare Advantage plan, which caps those expenses.

But during the past several years, dozens of effective drugs for cancer and other serious conditions have become available in oral form at the pharmacy. That means Medicare patients increasingly pay the Part D out-of-pocket costs with no set maximum.

“With the high cost of drugs today, that 5% can be a third or more of a patient’s Social Security check,” said Brian Connell, federal affairs director for the Leukemia & Lymphoma Society.

This has forced some older Americans to keep working, rather than retiring and going on Medicare, because their employer plan covers more of their drug costs. That way, they also can keep receiving financial help directly from drugmakers to pay for the costs not covered by their private plan, which isn’t allowed by Medicare.

‘This Is a Little Nuts’

All this has caused financial and emotional turmoil for people who face a life-threatening disease.

Marilyn Rose, who was diagnosed with chronic myeloid leukemia three years ago, until recently was paying nothing out-of-pocket for her cancer drug, Sprycel, which has a list price of $176,500 a year. That’s because Bristol Myers Squibb, the manufacturer, paid her insurance deductible and copays for the drug.

But the self-employed artist and designer, who lives in West Caldwell, New Jersey, recently turned 65 and went on Medicare. The Part D plan offering the best deal on Sprycel charges more than $10,000 a year in coinsurance for the drug.

Rose asked her oncologist if she could switch to an alternative medication, Gleevec, for which she’d pay just $445 a year. But she ultimately decided to stick with Sprycel, which her doctor said is a longer-lasting treatment. She hopes to qualify for financial aid from a foundation to cover the coinsurance but won’t know until sometime this month.

“It’s just strange you have to make a decision about your treatment based on your finances rather than what’s the right drug for you,” she said. “I always thought that when I get to Medicare age I’ll be able to breathe a sigh of relief. This is a little nuts.”

Given the sticker shock, many other patients choose not to fill a needed prescription, or delay filling it. Nearly half of patients who face a price of $2,000 or more for a cancer drug walk away from the pharmacy without it, according to a 2017 study. Fewer than half of Medicare patients with blood cancer received treatment within 90 days of their diagnosis, according to a 2019 study commissioned by the Leukemia & Lymphoma Society.

“If I didn’t do really well at scrounging free drugs and getting copay foundations to work with us, my patients wouldn’t get the drug, which is awful,” said Dr. Barbara McAneny, an oncologist in Albuquerque, New Mexico, and past president of the American Medical Association. “Patients would just say, ‘I can’t afford it. I’ll just die.’”

The high drug prices and coverage gaps have forced many patients to rely on complicated financial assistance programs offered by drug companies and foundations. Under federal rules, the foundations can help Medicare patients as long as they pay for drugs made by all manufacturers, not just by the company funding the foundation.

But Daniel Klein, CEO of the PAN Foundation, which provides drug copay assistance to more than 100,000 people a year, said there are more patients in need than his foundation and others like it can help.

“If you are a normal consumer, you don’t know much about any of this until you get sick and all of a sudden you find out you can’t afford your medication,” he said. Patients are lucky, he added, if their doctor knows how to navigate the charitable assistance maze.

Yet many don’t. Daniel Sherman, who trains hospital staff members to navigate financial issues for patients, estimates that fewer than 5% of U.S. cancer centers have experts on staff to help patients with problems paying for their care.

Sharon Clark, who struggles to cover her cancer drugs, works with the Leukemia & Lymphoma Society counseling other patients on how to access helping resources. “People tell me they haven’t started treatment because they don’t have money to pay,” she said. “No one in this country should have to choose between housing, food or medicine. It should never be that way, never.”

This article is part of a series on the impact of high prescription drug costs on consumers made possible through the 2020 West Health and Families USA Media Fellowship.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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With Vaccine Delivery Imminent, Nursing Homes Must Make a Strong Pitch to Residents

Imagine this: Your elderly mother, who has dementia, is in a nursing home and COVID-19 vaccines are due to arrive in a week or two.

You think she should be vaccinated, having heard the vaccine is effective in generating an immune response in older adults. Your brother disagrees. He worries that development of the vaccine was rushed and doesn’t want your mother to be among the first people to get it.

These kinds of conflicts are likely to arise as COVID vaccines are rolled out to long-term care facilities across the country.

“This is a highly politicized environment, not only with respect to vaccines but also over the existence of the virus itself,” said Michael Dark, a staff attorney with California Advocates for Nursing Home Reform. “It’s not hard to imagine disputes arising within families.”

About 3 million people — most of them elderly — live in nursing homes, assisted living centers and group homes, where more than 105,000 residents have died of COVID-19. They should be among the first Americans to receive vaccines, along with health care workers, according to recommendations from the Centers for Disease Control and Prevention and various state plans.

But long-term care residents’ participation in the fastest and most extensive vaccination effort in U.S. history is clouded by a significant complication: More than half have cognitive impairment or dementia.

This raises a number of questions. Will all older adults in long-term care understand the details of the vaccines and be able to consent to getting them? If individual consent isn’t possible, how will families and surrogate decision-makers get the information they need on a timely basis?

And what if surrogates don’t agree with the decision an elderly person has made and try to intervene?

“Imagine that the patient, who has some degree of cognitive impairment, says ‘yes’ to the vaccine but the surrogate says ‘no’ and tells the nursing home, ‘How dare you try to do this?” said Alta Charo, a professor of law and bioethics at the University of Wisconsin-Madison Law School.

Addressing these issues will occur against a backdrop of urgency. Deaths in long-term care facilities are rising dramatically, with new estimates suggesting that 19 residents die of COVID-19 every hour. With viral outbreaks increasing, already-overwhelmed staffers may not have much time to sit down with residents to answer questions or have conversations with families over the phone.

Meanwhile, CVS and Walgreens, the companies operating vaccine programs at most long-term care facilities, have aggressive timetables. Both companies have said the large-scale rollout of the Pfizer-BioNTech vaccine — the first one that the Food and Drug Administration has authorized — will begin on Dec. 21.But facilities in some states may get supplies earlier. Altogether, there are more than 15,000 nursing homes and nearly 29,000 assisted living residences in the U.S.

At a meeting of the federal Advisory Committee on Immunization Practices early this month, Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, acknowledged the agency was “very concerned” that information about vaccines be adequately explained to long-term care residents. “It’s very important for the frail elderly not only to ensure that they are understanding the vaccine that they’re getting but also that their family members do,” she said.

Each vaccine manufacturer will be required to prepare a fact sheet describing what’s known about benefits and risks associated with a vaccine, what’s not known, and making it clear that a vaccine has received “emergency use authorization” from the FDA — a conditional endorsement that falls short of full approval. A second vaccine, from Moderna, is poised to receive this kind of authorization after an FDA meeting on Thursday.

Something that will need to be made clear to residents: while vaccines have been tested on people age 65 and older, those tests did not include individuals living in long-term care, according to Dr. Sara Oliver, a CDC expert.

Some operators have crafted communication plans around the vaccines and already begun intensive outreach. Others may not be well prepared.

Juniper Communities operates 22 senior housing communities (a standalone nursing home, multiple memory care and assisted living facilities, and two continuing care retirement communities) in Colorado, New Jersey and Pennsylvania. This week, it is planning an hour-long town hall videoconferencing session for residents and families about coronavirus vaccines. Last week, it held a similar event for staffers.

Juniper has contracted with CVS, which is requiring that every resident and staff member fill out consent forms in triplicate before being inoculated. When written consent can’t be obtained directly, verbal consent, confirmed independently, may substitute. Walgreens has similar requirements.

For residents with memory impairment, two Juniper nurses will reach out by phone to whomever has decision-making authority. “One will ask questions and obtain verbal consent; the other will serve as a witness,” said Lynne Katzmann, Juniper’s founder and chief executive officer. Separately, emails, blog posts and prerecorded voice messages about the vaccines have gone out to Juniper residents and staffers, starting at the end of November.

A key message is “we’ve done this before, not at this scale, mind you, and not at this level of import, but we do flu vaccinations annually,” said Katzmann, who plans to be the first Juniper employee to get the Pfizer vaccine when it comes to New Jersey.

At Genesis Healthcare, crucial messages are “these vaccines have been studied thoroughly, tens of thousands of people have received them already, they’re very, very effective, and no steps have been skipped in the scientific process,” said Dr. Richard Feifer, executive vice president and chief medical officer. Genesis, the nation’s largest long-term care company, operates more than 380 nursing homes and assisted living residences in 26 states, with about 45,000 employees and more than 30,000 residents.

Medical directors at each Genesis facility have been scheduling video conferences with families, residents and staffers during the past few weeks to address concerns. They’ve also distributed a letter and a question-and-answer document prepared by the Society for Post-Acute and Long-Term Care Medicine, in addition to getting information out through closed-circuit TV channels and social media.

In partnership with Brown University researchers, the company will monitor daily the side effects that its long-term care residents experience after getting coronavirus vaccines. Most reactions are expected to be mild or moderate and resolve within a few days. They include fatigue, pain at the injection site, headaches, body aches, fever and, rarely, allergic responses.

Administering the vaccine will occur over three visits for all long-term care facilities. At the first, all Genesis residents and staffers will get inoculations. At the second, three to four weeks later, those same people will get a second dose, and new staffers and residents will get a first dose. At the third, those who still qualify for a second vaccine dose will get one.

What will happen if lots of people experience uncomfortable side effects and employees don’t come in for a couple of days while recovering? “It’s a very difficult problem and we’re making contingency plans to address it,” Feifer said.

And what about continuing care retirement communities — also known as “life plan communities” — where residents in skilled nursing, assisted living and independent living can reside in close proximity?

That’s the case at Bayview in Seattle, which houses 210 residents in a 10-story building. For the moment, independent living residents aren’t on the priority list but “I know there will be a contingent of residents and staff who won’t want to be vaccinated and we’ll see if we can use those vaccines for our independent living people instead,” said Joel Smith, Bayview’s health services administrator.

Logistical challenges are sure to arise, but many operators have an acute sense of mission. “It is critical that we lead the way out of this crisis,” Feifer of Genesis said. “Nursing homes need to go first and be the first ones to address vaccine hesitancy head-on and be successful at generating a high level of acceptance. There is no alternative, no Plan B right now. We have to be successful.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Alzheimer’s Inc.: Colleagues Question Scientist’s Pricey Recipe Against Memory Loss


This story also ran on Daily Beast. It can be republished for free.

When her husband was diagnosed with early-stage Alzheimer’s disease in 2015, Elizabeth Pan was devastated by the lack of options to slow his inevitable decline. But she was encouraged when she discovered the work of a UCLA neurologist, Dr. Dale Bredesen, who offered a comprehensive lifestyle management program to halt or even reverse cognitive decline in patients like her husband.

After decades of research, Bredesen had concluded that more than 36 drivers of Alzheimer’s cumulatively contribute to the loss of mental acuity. They range from chronic conditions like heart disease and diabetes to vitamin and hormonal deficiencies, undiagnosed infections and even long-term exposures to toxic substances. Bredesen’s impressive academic credentials lent legitimacy to his approach.

Pan paid $4,000 to a doctor trained in Bredesen’s program for a consultation and a series of extensive laboratory tests, then was referred to another doctor, who devised a stringent regimen of dietary changes that entailed cutting out all sugars, eating a high-fat, low-carbohydrate diet and adhering to a complex regimen of meditation, vigorous daily exercise and about a dozen nutritional supplements each day (at about $200 a month). Pan said she had extensive mold remediation done in her home after the Bredesen doctors told her the substance could be hurting her husband’s brain.

But two years passed, she said, and her husband, Wayne, was steadily declining. To make matters worse, he had lost more than 60 pounds because he didn’t like the food on the diet. In April, he died.

“I imagine it works in some people and doesn’t work in others,” said Pan, who lives in Oakton, Virginia. “But there’s no way to tell ahead of time if it will work for you.”

Bredesen wrote the best-selling 2017 book “The End of Alzheimer’s” and has promoted his ideas in talks to community groups around the country and in radio and TV appearances like “The Dr. Oz Show.” He has also started his own company, Apollo Health, to market his program and train and provide referrals for practitioners.

Unlike other self-help regimens, Bredesen said, his program is an intensely personalized and scientific approach to counteract each individual’s specific deficits by “optimizing the physical body and understanding the molecular drivers of the disease,” he told KHN in a November phone interview. “The vast majority of people improve” as long as they adhere to the regimen.

Bredesen’s peers acknowledge him as an expert on aging. A former postdoctoral fellow under Nobel laureate Stanley Prusiner at the University of California-San Francisco, Bredesen presided over a well-funded lab at UCLA for more than five years. He has been on the UCLA faculty since 1989 and also founded the Buck Institute for Research on Aging in Marin County. He has written or co-authored more than 200 papers.

But colleagues are critical of what they see as his commercial promotion of a largely unproven and costly regimen. They say he strays from long-established scientific norms by relying on anecdotal reports from patients, rather than providing evidence with rigorous research.

“He’s an exceptional scientist,” said George Perry, a neuroscientist at the University of Texas-San Antonio. “But monetizing this is a turnoff.”

“I have seen desperate patients and family members clean out their bank accounts and believe this will help them with every ounce of their being,” said Dr. Joanna Hellmuth, a neurologist in the Memory and Aging Center at UCSF. “They are clinging to hope.”

Many of the lifestyle changes Bredesen promotes are known to be helpful. “The protocol itself is based on very low-quality data, and I worry that vulnerable patients and family members may not understand that,” said Hellmuth. “He trained here” — at UCSF — “so he knows better.”

The Bredesen package doesn’t come cheap. He has built a network of practitioner-followers by training them in his protocol — at $1,800 a pop — in seminars sponsored by the Institute for Functional Medicine, which emphasizes alternative approaches to managing disease. Apollo Health also offers two-week training sessions for a $1,500 fee.

Once trained in his ReCODE Protocol, medical professionals charge patients upward of $300 for a consultation and as much as $10,500 for eight- to 15-month treatment packages. For the ReCODE protocol, aimed at people already suffering from early-stage Alzheimer’s disease or mild cognitive decline, Apollo Health charges an initial $1,399 fee for a referral to a local practitioner that includes an assessment and extensive laboratory tests. Apollo then offers $75-per-month subscriptions that provide cognitive games and online support, and links to another company that offers dietary supplements for an additional $150 to $450 a month. Insurance generally covers little of these costs.

Apollo Health, founded in 1998 and headquartered in Burlingame, California, also offers a protocol geared toward those who have a family history of dementia or want to prevent cognitive decline.

Bredesen estimates that about 5,000 people have done the ReCODE program. The fees are a bargain, Bredesen said, if they slow decline enough to prevent someone from being placed in a nursing home, where yearly costs can climb past $100,000 annually.

Bredesen and his company are tapping into the desperation that has grown out of the failure of a decades-long scientific quest for effective Alzheimer’s treatments. Much of the research money in the field has narrowly focused on amyloid — the barnacle-like gunk that collects outside nerve cells and interferes with the brain’s signaling system — as the main culprits behind cognitive decline. Drugmakers have tried repeatedly, and thus far without much success, to invent a trillion-dollar anti-amyloid drug. There’s been less emphasis in the field on the lifestyle choices that Bredesen stresses.

“Amyloids sucked up all the air in the room,” said Dr. Lon Schneider, an Alzheimer’s researcher and a professor of psychiatry and behavioral sciences at the Keck School of Medicine at USC.

Growing evidence shows lifestyle changes help delay the progress of the mind-robbing disease. An exhaustive Lancet report in August identified a long list of risk factors for dementia, including excessive drinking, exposure to air pollution, obesity, loss of hearing, smoking, depression, lack of exercise and social isolation. Controlling these factors — which can be done on the cheap — could delay or even prevent up to 40% of dementia cases, according to the report.

Bredesen’s program involves all these practices, with personalized bells and whistles like intermittent fasting, meditation and supplements. Bredesen’s scientific peers question whether data supports his micromanaged approach over plain-vanilla healthy living.

Bredesen has published three papers showing positive results in many patients following his approach, but critics say he has fallen short of proving his method’s effectiveness.

The papers lack details on which protocol elements were followed, or the treatment duration, UCSF’s Hellmuth said. Nor do they explain how cognitive tests were conducted or evaluated, so it’s difficult to gauge whether improvements were due to the intervention, to chance variations in performance or an assortment of other variables, she said.

Bredesen shrugs off the criticism: “We want things to be in an open-access journal so everybody can read it. These are still peer-reviewed journals. So what’s the problem?”

Another problem raised about Bredesen’s enterprise is the lack of quality control, which he acknowledges. Apollo-trained “certified practitioners” can include everyone from nurses and dietitians to chiropractors and health coaches. Practitioners with varying degrees of training and competence can take his classes and hang out a shingle. That’s a painful fact for some who buy the package.

“I had the impression these practitioners were certified, but I realize they all had just taken a two-week course,” said a Virginia man who requested anonymity to protect his wife’s privacy. He said that he had spent more than $15,000 on tests and treatments for his ailing spouse and that six months into the program, earlier this year, she had failed to improve.

Bredesen said he and his staff were reviewing “who’s getting the best results and who’s getting the worst results,” and intended to cut poor performers out of the network. “We’ll make it so that you can only see the people getting the best results,” he said.

Colleagues say that to test whether Bredesen’s method works it needs to be subjected to a placebo-controlled study, the gold standard of medical research, in which half the participants get the treatment while the other half don’t.

In the absence of rigorous studies, said USC’s Schneider, a co-author of the Lancet report, “saying you can ‘end Alzheimer’s now and this is how you do it’ is overpromising and oversimplifying. And a lot of it is just common sense.”

Bredesen no longer says his method can end Alzheimer’s, despite the title of his book. Apollo Health’s website still makes that claim, however.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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I Found My Secret to Feeling Younger and Stronger. The Pandemic Stole It Away.

Back in early January, before COVID-19 was as familiar as the furniture, I went in for my annual physical. My doctor looked at my test results and shook his head. Virtually everything was perfect. My cholesterol was down. So was my weight. My blood pressure was that of a swimmer. A barrage of blood tests turned up zero red flags.

“What are you doing differently?” he asked, almost dumbfounded.

After all, I’m a 67-year-old balding guy who had spent much of his life as a desk-bound journalist dealing with nasty ailments like hernias (in my 30s), kidney stones (40s) and shingles (50s).

I ruminated over what had changed since my last physical. Sure, I exercise more than 90 minutes daily, but I’ve been doing that for five years. And yes, I watch what I eat, but that’s not new. Like most families with college-age kids, mine has its share of emotional and financial stresses — and there’d been no let-up there.

Only one thing in my life had registered any real change. “I’m volunteering more,” I told him.

I’d been spending less time in my basement office and more time out doing some good with like-minded people. Was this the magic elixir that seemed to steadily improve my health?

All signs pointed to “yes.” And I was feeling great about it.

Then just as I realized how important volunteering is to my health and well-being, the novel coronavirus appeared. As cases climbed, society shut down. One by one, my beloved volunteer gigs in Virginia disappeared. No more Mondays at Riverbend Park in Great Falls helping folks decide which trails to walk. Or Wednesdays serving lunch to the homeless at a community shelter in Falls Church. Or Fridays at the Arlington Food Assistance Center, which I gave up out of an abundance of caution. My modest asthma is just the sort of underlying condition that seems to make COVID-19 all the more brutal.

It used to be that missing even one day of volunteering made me feel like a sourpuss. After almost eight months without it, I’m downright dour.

Science helps explain why.

“The health benefits for older volunteers are mind-blowing,” said Paul Irving, chairman of the Center for the Future of Aging at the Milken Institute, and distinguished scholar in residence at the USC Leonard Davis School of Gerontology, whose lectures, books and podcasts on aging are turning heads.

When older folks go in for physicals, he said, “in addition to taking blood and doing all the other things that the doctor does when he or she pushes and prods and pokes, the doctor should say to you, ‘So, tell me about your volunteering.’”

A 2016 study in Psychosomatic Medicine: Journal of Behavioral Medicine that pooled data from 10 studies found that people with a higher sense of purpose in their lives — such as that received from volunteering — were less likely to die in the near term. Another study, published in Daedalus, an academic journal by MIT Press for the American Academy of Arts & Sciences, concluded that older volunteers had reduced risk of hypertension, delayed physical disability, enhanced cognition and lower mortality.

“People who are happy and engaged show better physiological functioning,” said Dr. Alan Rozanski, a cardiologist at Mount Sinai St. Luke’s Hospital, a senior author of the Psychosomatic Medicine study. People who engage in social activities such as volunteering, he said, often showed better blood pressure results and better heart rates.

That makes sense, of course, because volunteers are typically more active than, say, someone home on the couch streaming “Gilligan’s Island.”

Volunteers share a dirty little secret. We may start it to help others, but we stick with it for our own good, emotionally and physically.

At the homeless shelter, I could hit my target heart rate packing 50 sack lunches in an hour to the beat of Motown music. And at the food bank, I could feel the physical and emotional uplift of human contact while distributing hundreds of gallons of milk and dozens of cartons of eggs during my three-hour shifts. When I’m volunteering, I dare say I feel more like 37 than 67.

None of this surprises Rozanski, who looked at 10 studies over the past 15 years that included more than 130,000 participants. All of them, he said, showed that partaking in activities with purpose — such as volunteering — reduced the risk of cardiovascular events and often resulted in a longer life for older people.

Dr. David DeHart knows something about this, too. He’s a doctor of family medicine at the Mayo Clinic in Prairie du Chien, Wisconsin. He figures he has worked with thousands of patients — many of them elderly — over his career. Instead of just writing prescriptions, he recommends volunteering to his older patients primarily as a stress reducer.

“Compassionate actions that relieve someone else’s pain can help to reduce your own pain and discomfort,” he said.

At age 50, he listens to his own advice. DeHart volunteers with international medical teams in Vietnam, typically two trips a year. He often brings his wife and children to help, too. “When I come back, I feel recharged and ready to jump back into my work here,” he said. “The energy it gives me reminds me why I wanted to be a doctor in the first place.”

I think of my personal rewards from volunteering as cosmic electricity — with no “off” button. The good feeling sticks with me throughout the week — if not the month.

When will it be safe to resume my volunteering activities?

I’m considering my options. The park is offering some outdoor opportunities involving cleanup, but that lacks the interaction that lifts me. I’m tempted to go back to the food bank because even Charles Dinkens, an 85-year-old who has volunteered next to me for years, has returned after eight months away. “What else am I supposed to do?” he posed. The homeless shelter isn’t allowing volunteers in just yet. Instead, it’s asking folks to bag lunches at home and drop them off. Oh, they’re also looking for people to “call” virtual games of bingo for residents.

Virtual bingo just doesn’t float my boat.

Truth be told, there is no one-size-fits-all way to safely volunteer during the pandemic, said Dr. Kristin Englund, staff physician and infectious disease expert at the Cleveland Clinic. She suggests that volunteers — particularly those over 65 — stick with outdoor options. It’s better in a protected space where the general public isn’t moving through, she said, because “every time you interact with a person, it increases your risk of contracting the disease.”

Englund said she’d consider walking dogs outside for a local animal shelter as one safe option with some companionship. “While we do know that people can give COVID to animals,” she said, “it’s unlikely they can give it back to you.”

Meanwhile, my next annual physical is coming right up in January. It’s got me to wondering if my labs will be quite as pristine as they were the last go-round. I’ve got my doubts. Unless, of course, I’ve resumed some sort of in-person volunteering by then.

Last year, an elderly woman staying at the homeless shelter pulled me aside to thank me after I handed her lunch of tomato soup and a turkey sandwich. She set down her tray, took my hand, looked me smack in the eye and asked, “Why do you do this?”

She was probably expecting me to say I do it to help others because I care about those less fortunate than me. But that’s not what came out.

“I do it for myself,” I said. “Being here makes me whole.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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What Seniors Can Expect When COVID Vaccines Begin to Roll Out

Vaccines that protect against COVID-19 are on the way. What should older adults expect?

The first candidates, from Pfizer and Moderna, could arrive before Christmas, according to Alex Azar, who heads the Department of Health and Human Services.

Both vaccines are notably effective in preventing illness due to the coronavirus, according to information released by the companies, although much of the data from clinical trials is still to come. Both have been tested in adults age 65 and older, who mounted a strong immune response.

Seniors in nursing homes and assisted living centers will be among the first Americans vaccinated, following recommendations last week by a federal advisory panel. Older adults living at home will need to wait a while longer.

Many uncertainties remain. Among them: What side effects can older adults anticipate and how often will these occur? Will the vaccines offer meaningful protection to seniors who are frail or have multiple chronic illnesses?

Here’s a look at what’s known, what’s not and what lies ahead.

Decision-making timetable. Pfizer’s vaccine will be evaluated by a 15-member Food and Drug Administration advisory panel on Thursday. Moderna’s vaccine is expected to go before the panel Dec. 17.

At least two days before each meeting, an analysis by FDA staff will be made public. This will be the first opportunity to see extensive data about the vaccines’ performance in large phase 3 clinical trials, including more details about their impact on older adults.

So far, summary results disclosed in news releases indicate that Pfizer’s vaccine, produced in partnership with BioNTech, has an overall efficacy rate of 95% and efficacy of 94% in people 65 and older. Moderna’s overall efficacy is 94%, with 87% efficacy in preventing moderate disease in older adults, according to Moncef Slaoui, chief science adviser to Operation Warp Speed, the government’s COVID-19 vaccine development program.

If the advisory panel gives a green light, the FDA will decide within days or weeks whether to authorize the Pfizer and Moderna vaccines for emergency use. Distribution of the vaccine has already begun, and health care providers are expected to begin administering it immediately after the FDA acts.

Allocation framework. At a Dec. 1 meeting of the Advisory Commission on Immunization Practices (ACIP), which guides the Centers for Disease Control and Prevention on vaccines, experts recommended that people living in long-term care (primarily nursing homes and assisted living facilities) and health care workers be the first groups to get COVID-19 vaccines.

This recognizes the extraordinary burden of COVID-19 in long-term care facilities. Although their residents represent fewer than 1% of the U.S. population, they account for 40% of COVID deaths — more than 100,000 deaths to date.

The commission’s decision comes despite a lack of evidence that Pfizer’s and Moderna’s vaccines are effective and safe for frail, vulnerable seniors in long-term care. Vaccines were not tested in this population. Federal officials insist side effects will be carefully monitored.

Next in line likely would be essential workers who cannot work from home, such as police, firefighters, teachers and people employed in food processing and transportation, according to commission deliberations Nov. 23 that have not come to a formal vote.

Then would be adults with high-risk medical conditions such as diabetes, cancer, kidney disease, obesity, heart disease and autoimmune diseases and all adults age 65 and older.

Although states typically follow ACIP guidelines, some states may choose, for instance, to vaccinate high-risk older adults before some categories of essential workers.

Left off the list are family caregivers, who provide essential support to vulnerable older adults living in the community — an unpaid workforce of tens of millions of people. “If someone is providing day-to-day care, it makes sense they should have access to the vaccine, too, to keep everyone safe,” said Beth Kallmyer, vice president of care and support for the Alzheimer’s Association.

Further prioritization. The priority groups constitute nearly half of the U.S. population — 21 million health care workers, 3 million long-term care residents, 66 million essential workers, more than 100 million adults with high-risk conditions and 53 million adults age 65 and older.

With initial supplies of vaccines limited, setting priorities will be inevitable. Practically, this means that hospitals and physicians may try to identify older adults who are at the highest risk of becoming seriously ill from COVID-19 and offer them vaccines before other seniors.

A study of more than 500,000 Medicare beneficiaries age 65 and older provides new evidence that could influence these assessments. It found the conditions that most increase older adults’ chances of dying from COVID-19 are sickle cell disease, chronic kidney disease, leukemias and lymphomas, heart failure, diabetes, cerebral palsy, obesity, lung cancer and heart attacks, in that order.

“Out of all Medicare beneficiaries, we identified just under 2,500 who had no medical problems and died of COVID-19,” said Dr. Martin Makary, co-author of the study and a professor of health policy and management at Johns Hopkins Bloomberg School of Public Health in Baltimore. “We knew risk was skewed toward comorbidity [multiple underlying medical conditions], but we didn’t realize it skewed this much.”

Supplies available. Both the Pfizer and Moderna vaccines require two doses, administered three to four weeks apart. The companies have said about 40 million doses of their vaccines should be available this year, enough to fully vaccinate about 20 million people.

After that, 50 million doses might become available in January, followed by 60 million doses in both February and March, according to Dr. Larry Corey, a virologist who heads the COVID-19 Prevention Trials Network.

That translates into enough vaccine for another 85 million people and should be sufficient to vaccinate older adults in addition to medical personnel on the front lines and many other at-risk individuals, Corey suggested at a recent panel on COVID-19 sponsored by the National Academy of Medicine and American Public Health Association.

He acknowledged these were estimates, based on information he has been given. Pfizer and Moderna have not yet specified how much vaccine will be delivered and when. Nor is it clear when other vaccines under investigation will become available — 13 are in phase 3 clinical trials — or what their monthly production capacity might be.

Distribution issues. As Pfizer’s and Moderna’s vaccines are rolled out, a very vulnerable group may have difficulty getting them: 2 million seniors who are homebound and another 5.3 million with physical impairments who have problems getting around.

The reason: handling and cold storage requirements.

Pfizer’s vaccine needs to be stored at minus 70 degrees Celsius, calling for special equipment not available in small hospitals, clinics or doctors’ offices. Moderna’s vaccine needs long-term storage at minus 20 degrees Celsius.

Landmark Health provides in-home medical care to more than 120,000 frail, chronically ill homebound seniors in 15 states. “We don’t have the capabilities to store and distribute these vaccines to our population,” said Dr. Michael Le, the company’s co-founder and chief medical officer.

Instead, he said, Landmark is working to arrange transportation for its patients to centers where COVID-19 vaccines will be administered and educating them about the benefits of the vaccines. “Given the trust, the bond we have with our patients, we can play a big role as advocates,” Le said.

Addressing mistrust. Advocates have a big job ahead of them. According to a recent poll from the University of Michigan, only 58% of older adults (ages 50 to 80) said they were very or somewhat likely to get a COVID-19 vaccine. A significant number of older adults, 46%, thought they’d get the vaccine eventually but wanted others to go first. Only 20% wanted to get it as soon as possible.

Most important in making decisions is knowing how well the vaccine works, according to 80% of the 1,556 older adults surveyed. Just over half (52%) said a recommendation from their doctor would be influential.

Dr. Sharon Inouye, a geriatrician at Hebrew Senior Life in Boston and a professor of medicine at Harvard Medical School, is among the physicians impatiently awaiting the publication of data from Pfizer’s and Moderna’s phase 3 clinical trials.

Among the things she wants to know: How many older adults with chronic health conditions participated? How many participants were 75 and older? Did side effects differ for older adults?

“What I worry about most is the side effects,” she said. “We may not be able to know about serious but rare side effects until millions of people take them.”

But that’s a gamble she’s willing to take. Not only will Inouye get a vaccine, she just told her 91-year-old mother, who lives in assisted living, to say “yes” when one is offered.

“My whole family lives in fear that something will happen to her every day,” Inouye said. “Even though there’s a lot we still don’t know about these vaccines, it’s compelling that we protect people from this overwhelming illness.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Medicare Open Enrollment Is Complicated. Here’s How to Get Good Advice.

If you’ve been watching TV lately, you may have seen actor Danny Glover or Joe Namath, the 77-year-old NFL legend, urging you to call an 800 number to get fabulous extra benefits from Medicare.

There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.

Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.

This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.

For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.

The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.

Costs and benefits among the multitude of competing Medicare plans vary widely, and the maze of rules and other details can be overwhelming. Indeed, information overload is part of the reason a majority of the more than 60 million people on Medicare, including over 6 million in California, do not comparison-shop or switch to more suitable plans.

“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”

Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.

Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.

But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.

Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.

However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.

“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.

You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at www.shiptacenter.org.

Medicare & You, a comprehensive handbook, is worth reading. Download it at the official Medicare website, www.medicare.gov.

The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.

The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.

California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.

These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.

If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.

Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.

Beware of the risks, however.

Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)

However, Medigap policies will often protect you against large medical bills if you need lots of care.

In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.

Over one-third of Medicare beneficiaries nationally are enrolled in Advantage plans. In California, about 40% are.

The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.

Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.

“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”

Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.

There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.

Make sure you understand the rules and exceptions that apply to you.

Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.

When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.”



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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These Front-Line Workers Could Have Retired. They Risked Their Lives Instead.

Sonia Brown’s husband died on June 10. Two weeks later, the 65-year-old registered nurse was back at work. Her husband’s medical bills and a car payment loomed over her head.

“She wanted to make sure all those things were taken care of before she retired,” her son David said.

David and his sister begged her not to go back to work during the coronavirus pandemic — explaining their concerns about her age and diabetes — but she didn’t listen.

“She was like the Little Engine That Could. She just powered through everything,” David said.

But her invincibility couldn’t withstand COVID-19, and on 29 July she died after contracting the deadly virus.

Sonia’s death is far from unusual. Despite evidence from the Centers for Disease Control and Prevention that adults 65 and older are at a higher risk from COVID-19, KHN and The Guardian have found that 338 front-line workers in that age group continued to work and likely died of complications from the virus after exposure on the job. Some were in their 80s — oftentimes physicians or registered nurses who cherished decades-long relationships with their patients and didn’t see retirement as an option.

The aging workers had a variety of motivations for risking their lives during the pandemic. Some felt pressured by employers to compensate for staffing shortages as the virus swept through departments. Others felt a higher sense of duty to their profession. Now their families are left to grapple with the same question: Would their loved one still be alive if he or she had stayed home?

‘All of This Could Have Been Prevented’

Aleyamma John was what her son, Ginu, described as a “prayerful woman.” Her solace came from working and caring for others. Her 38-year nursing career started in Mumbai, India. She immigrated with her husband to Dubai in the United Arab Emirates, where she worked for several years and had her two children. In 2002, the family moved to New York, and she took a job at NYC Health + Hospitals in Queens.

In early March, as cases surged across New York, Ginu asked his 65-year-old mother to retire. Her lungs were already weakened by an inflammatory disease, sarcoidosis.

“We told her very clearly, ‘Mom, this isn’t something that we should take lightly, and you definitely need to stay home.’”

“I don’t feel like the hospital will allow me to do that,” she responded.

Ginu described the camaraderie his mother shared with her co-workers, a bond that grew deeper during the pandemic. Many of her fellow nurses got sick themselves, and Aleyamma felt she had to step up.

Some of her co-workers “were quarantined [and did] not come into work,” he said. “Her department took a pretty heavy hit.”

By the third week of March, she started showing symptoms of COVID-19. A few days in, she suggested it might be best for her to go to the hospital.

“I think she knew it was not going to go well,” Ginu said. “But she found it in her heart to give us strength, which I thought was just insanely brave.”

Aleyamma ended up on a ventilator, something she assured Ginu wouldn’t be necessary. Her family was observing a virtual Palm Sunday service on 5 April when they got the call that she had died.

“We prayed that she would be able to come back, but that didn’t happen,” Ginu said.

Aleyamma and her husband, Johnny, who retired a few years ago, had been waiting to begin their next adventure.

“If organizations cared about their staff, especially staff who were vulnerable, if they provided for them and protected them, all of this could have been prevented,” Ginu said.

Commitment to Their Oath

In non-pandemic times, Sheena Miles considered herself semi-retired. She worked every other weekend at Scott Regional Hospital in Morton, Mississippi, mainly because she loved nursing and her patients. When Scott County emerged as a hot spot for the virus, Sheena worked four weekends in a row.

Her son, Tom, a member of Mississippi’s House of Representatives, called her one night to remind her she did not need to go to work.

“You don’t understand,” Sheena told her son. “I have an oath to do this. I don’t have a choice.”

Over Easter weekend, she began exhibiting COVID-like symptoms. By Thursday, her husband drove her to the University of Mississippi Medical Center in Jackson.

“She walked in and she never came out,” Tom said.

Tom said his mom “laid her life down” for the residents of Morton.

“She knew the chances that she was taking,” he said. “She just felt it was her duty to serve and to be there for people.”

Serving the community also was at the heart of Dr. Robert “Ray” Hull’s family medicine clinic in Rogers, Arkansas. He opened the clinic in 1972 and, according to his son Keith, had no intentions of leaving until his last breath.

“He was one of the first family physicians in northwest Arkansas,” Keith said. “Several people asked him if he was going to retire. His answer was always no.”

At the ripe age of 78, Dr. Hull continued to make house calls, black bag in hand. His wife worked alongside him in the office. Keith said the whole staff took proper precautions to keep the virus at bay, so when his father tested positive for COVID-19, it came as a shock.

Keith wasn’t able to visit his father at the hospital before he died on June 7. He said the funeral was even harder. Due to COVID restrictions on crowd sizes, he had to ask patients from Arkansas, Oklahoma and Missouri to stay home.

“There’s not a coliseum, arena or stadium that would have held his funeral,” Keith said. “Everybody knew my dad.”

‘She Was Afraid She Was Going to Get Sick’

Nancy MacDonald, at 74, got bored at home. That’s why her daughter, Bethany, said retirement never stuck for her. So in 2017, Nancy took a job as a receptionist at Orchard View Manor, a nursing home in East Providence, Rhode Island.

Although technically she worked the night shift, her co-workers could rely on her to pick up extra shifts without question.

“If somebody called her and said, ‘Oh, I’m not feeling well. I can’t come in,’ she was right there. That was just the way she was,” Bethany said.

Nursing homes across the country have struggled to contain breakouts of COVID-19, and Orchard View was no exception. By mid-April, the facility reportedly had 20 deaths. Nancy’s position was high-contact; residents and staff were in and out of the reception area all day.

At the onset of the pandemic, Orchard View had a limited supply of PPE. Bethany said they prioritized giving it to workers “on the floor,” primarily those handling patient care. Her mother’s position was on the back burner.

“When they gave her a[n N95] mask, they also gave her a brown paper bag,” she said. “When she left work, they told her to put the mask in the bag.”

Nancy’s managers reiterated that she was an essential employee, so she continued showing up. In personal conversations with her daughter, however, she was fearful about what might happen. At her age, she was considered high-risk. Nancy saw the isolation that Orchard View residents experienced when they contracted the coronavirus. She didn’t want that to be her.

“She was afraid she was going to get sick,” Bethany said. “She was afraid to die alone.”

Following her death on April 25, the Occupational Safety and Health Administration opened an investigation into the facility. So far, Orchard View has been fined more than $15,000 for insufficient respiratory protection and recording criteria.

A spokesperson for Orchard View told KHN the facility had “extensive infection control.” The facility declined to comment further.

Bethany MacDonald believes health care systems often exclude receptionists, janitors and technical workers from conversations on protecting the front line.

“It doesn’t matter what the job is, they are on the front line. You don’t have to be a doctor to be on the front line,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Long-Term Care Workers, Grieving and Under Siege, Brace for COVID’s Next Round

In the middle of the night, Stefania Silvestri lies in bed remembering her elderly patients’ cries.

“Help me.”

“Please don’t leave me.”

“I need my family.”

Months of caring for older adults in a Rhode Island nursing home ravaged by COVID-19 have taken a steep toll on Silvestri, 37, a registered nurse.

She can’t sleep, as she replays memories of residents who became ill and died. She’s gained 45 pounds. “I have anxiety. Some days I don’t want to get out of bed,” she said.

Now, as the coronavirus surges around the country, Silvestri and hundreds of thousands of workers in nursing homes and assisted living centers are watching cases rise in long-term care facilities with a sense of dread.

Many of these workers struggle with grief over the suffering they’ve witnessed, both at work and in their communities. Some, like Silvestri, have been infected with the coronavirus and recovered physically — but not emotionally.

Since the start of the pandemic, more than 616,000 residents and employees at long-term care facilities have been struck by COVID-19, according to the latest data from KFF. Just over 91,000 have died as the coronavirus has invaded nearly 23,000 facilities. (KHN is an editorially independent program of KFF.)

At least 1,000 of those deaths represent certified nursing assistants, nurses and other people who work in institutions that care for older adults, according to a recent analysis of government data by Harold Pollack, a professor at the School of Social Service Administration at the University of Chicago. This is almost certainly an undercount, he said, because of incomplete data reporting.

How are long-term care workers affected by the losses they’re experiencing, including the deaths of colleagues and residents they’ve cared for, often for many years?

Edwina Gobewoe, a certified nursing assistant who has worked at Charlesgate Nursing Center in Providence, Rhode Island, for nearly 20 years, acknowledged “it’s been overwhelming for me, personally.”

At least 15 residents died of COVID-19 at Charlesgate from April to June, many of them suddenly. “One day, we hear our resident has breathing problems, needs oxygen, and then a few days later they pass,” she said. “Families couldn’t come in. We were the only people with them, holding their hands. It made me very, very sad.”

Every morning, Gobewoe would pray with a close friend at work. “We asked the Lord to give us strength so we could take care of these people who needed us so much.” When that colleague was struck by COVID-19 in the spring, Gobewoe prayed for her recovery and was glad when she returned to work several weeks later.

But sorrow followed in early September: Gobewoe’s friend collapsed and died at home while complaining of unusual chest pain. Gobewoe was told that her death was caused by blood clots, which can be a dangerous complication of COVID-19.

She would “do anything for any resident,” Gobewoe remembered, sobbing. “It’s too much, something you can’t even talk about,” describing her grief.

I first spoke to Kim Sangrey, 52, of Lancaster, Pennsylvania, in July. She was distraught over the deaths of 36 residents in March and April at the nursing home where she’s worked for several decades — most of them due to COVID-19 and related complications. Sangrey, a recreational therapist, asked me not to name the home, where she continues to be employed.

“You know residents like family — their likes and dislikes, the food they prefer, their families, their grandchildren,” she explained. “They depend on us for everything.”

When COVID-19 hit, “it was horrible,” she said. “You’d go into residents’ rooms and they couldn’t breathe. Their families wanted to see them, and we’d set up Zoom wearing full gear, head to toe. Tears are flowing under your mask as you watch this person that you loved dying — and the family mourning their death through a tablet.”

“It was completely devastating. It runs through your memory — you think about it all the time.”

Mostly, Sangrey said, she felt empty and exhausted. “You feel like this is never going to end — you feel defeated. But you have to continue moving forward,” she told me.

Three months later, when we spoke again, COVID-19 cases were rising in Pennsylvania but Sangrey sounded resolute. She’d had six sessions with a grief counselor and said it had become clear that “my purpose at this point is to take every ounce of strength I have and move through this second wave of COVID.”

“As human beings, it is our duty to be there for each other,” she continued. “You say to yourself, OK, I got through this last time, I can get through it again.”

That doesn’t mean that fear is absent. “All of us know COVID-19 is coming. Every day we say, ‘Is today the day it will come back? Is today the day I’ll find out I have it?’ It never leaves you.”

To this day, Silvestri feels horrified when she thinks about the end of March and early April at Greenville Center in Rhode Island, where up to 79 residents became ill with COVID-19 and at least 20 have died.

The coronavirus moved through the facility like wildfire. “You’re putting one patient on oxygen and the patient in the next room is on the floor but you can’t go to them yet,” Silvestri remembered. “And the patient down the hall has a fever of 103 and they’re screaming, ‘Help me, help me.’ But you can’t go to him either.”

“I left work every day crying. It was heartbreaking — and I felt I couldn’t do enough to save them.”

Then, there were the body bags. “You put this person who feels like family in a plastic body bag and wheel them out on a frame with wheels through the facility, by other residents’ rooms,” said Silvestri, who can’t smell certain kinds of plastic without reliving these memories. “Thinking back on it makes me feel physically ill.”

Silvestri, who has three children, developed a relatively mild case of COVID-19 in late April and returned to work several weeks later. Her husband, Michael, also became ill and lost his job as a truck driver. After several months of being unemployed, he’s now working at a construction site.

Since July 1, the family has gone without health insurance, “so I’m not able to get counseling to deal with the emotional side of what’s happened,” Silvestri said.

Although her nursing home set up a hotline number that employees could call, that doesn’t appeal to her. “Being on the phone with someone you don’t know, that doesn’t do it for me,” she said. “We definitely need more emotional support for health care workers.”

What does help is family. “I’ve leaned on my husband a lot and he’s been there for me,” Silvestri said. “And the children are OK. I’m grateful for what I have — but I’m really worried about what lies ahead.”

The Navigating Aging column last week focused on how nursing homes respond to grief sweeping through their facilities.

Join Judith Graham for a Facebook Live event on grief and bereavement during the coronavirus pandemic on Monday, Nov. 16, at 1 p.m. ET. You can watch the conversation here and submit questions in advance here.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Prayers and Grief Counseling After COVID: Trying to Aid Healing in Long-Term Care

A tidal wave of grief and loss has rolled through long-term care facilities as the coronavirus pandemic has killed more than 91,000 residents and staffers — nearly 40% of recorded COVID-19 deaths in the U.S.

And it’s not over: Facilities are bracing for further shocks as coronavirus cases rise across the country.

Workers are already emotionally drained and exhausted after staffing the front lines — and putting themselves at significant risk — since March, when the pandemic took hold. And residents are suffering deeply from losing people they once saw daily, the disruption of routines and being cut off from friends and family.

In response, nursing homes and assisted living centers are holding memorials for people who’ve died, having chaplains and social workers help residents and staff, and bringing in hospice providers to offer grief counseling, among other strategies. More than 2 million vulnerable older adults live in these facilities.

“Everyone is aware that this is a stressful, traumatic time, with no end in sight, and there needs to be some sort of intervention,” said Barbara Speedling, a long-term care consultant working on these issues with the American Health Care Association and National Center for Assisted Living, an industry organization.

Connie Graham, 65, is corporate chaplain at Community Health Services of Georgia, which operates 56 nursing homes. For months, he’s been holding socially distant prayer services in the homes’ parking lots for residents and staff members.

“People want prayers for friends in the facilities who’ve passed away, for relatives and friends who’ve passed away, for the safety of their families, for the loss of visitation, for healing, for the strength and perseverance to hold on,” Graham said.

Central Baptist Village, a Norridge, Illinois, nursing home, held a socially distanced garden ceremony to honor a beloved nurse who had died of COVID-19. “Our social service director made a wonderful collage of photos and left Post-its so everyone could write a memory” before delivering it to the nurse’s wife, said Dawn Mondschein, the nursing home’s chief executive officer.

“There’s a steady level of anxiety, with spikes of frustration and depression,” Mondschein said of staff members and residents.

Vitas Healthcare, a hospice provider in 14 states and the District of Columbia, has created occasional “virtual blessing services” on Zoom for staffers at nursing homes and assisted living centers. “We thank them for their service and a chaplain gives words of encouragement,” said Robin Fiorelli, Vitas’ senior director of bereavement and volunteers.

Vitas has also been holding virtual memorials via Zoom to recognize residents who’ve died of COVID-19. “A big part of that service is giving other residents an opportunity to share their memories and honor those they’ve lost,” Fiorelli said.

On Dec. 6, Hospice Savannah is going one step further and planning an online broadcast of its annual national “Tree of Light” memorial, with grief counselors who will offer healing strategies. During the service, candles will be lit and a moment of silence observed in remembrance of people who’ve died.

“Grief has become an urgent mental health issue, and we hope this will help begin the healing process for people who haven’t been able to participate in rituals or receive the comfort and support they’d normally have gotten prior to COVID-19,” said Kathleen Benton, Hospice Savannah’s president and chief executive officer.

But these and other attempts are hardly equal to the extent of anguish, which has only grown as the pandemic stretches on, fueling a mental health crisis in long-term care.

“There is a desperate need for psychological services,” said Toni Miles, a professor at the University of Georgia’s College of Public Health and an expert on grief and bereavement in long-term care settings. She’s created two guides to help grieving staffers and residents and is distributing them digitally to more than 400 nursing homes and 1,000 assisted living centers in the state.

A recent survey by Altarum, a nonprofit research and consulting firm, highlights the hopelessness of many nursing home residents. The survey asked 365 people living in nursing homes about their experiences in July and August.

“I am completely isolated. I might as well be buried already,” one resident wrote. “There is no hope,” another said. “I feel like giving up. … No emotional support nor mental health support is available to me,” another complained.

Inadequate mental health services in nursing homes have been a problem for years. Instead of counseling, residents are typically given medications to ease symptoms of distress, said David Grabowski, a professor of health care policy at Harvard Medical School who has published several studies on this topic.

The situation has worsened during the pandemic as psychologists and social workers have been unable to enter facilities that limited outsiders to minimize the risk of viral transmission.

“Several facilities didn’t consider mental health professionals ‘essential’ health care providers, and many of us weren’t able to get in,” said Lisa Lind, president of Psychologists in Long-Term Care. Although some facilities switched to tele-mental health services, staff shortages have made those hard to arrange, she noted.

Fewer than half of nursing home staffers have health insurance, and those who do typically don’t have “minimal” access to mental health services, Grabowski said. That’s a problem because “there’s a real fragility right now on the part of the workforce.”

Colleen Frankenfield, president and chief executive officer of Lutheran Social Ministries of New Jersey, said what staffers need most of all is “the ability to vent and to have someone comfort them.” She recalls a horrible day in April, when four residents died in less than 24 hours at her organization’s continuing care retirement community in northern New Jersey, which includes an assisted living facility and a nursing home.

“The phone rang at 1 a.m. and all I heard on the other end was an administrator, sobbing,” she remembered. “She said she felt she was emotionally falling apart. She felt like she was responsible for the residents who had died, like she had let them down. She just had to talk about what she was experiencing and cry it out.”

Although Lutheran Social Ministries has been free of COVID-19 since the end of April, “our employees are tired — always on edge, always worried,” Frankenfield said. “I think people are afraid and they need time to heal. At the end of the day, all we can really do is stand with them, listen to them and support them in whatever way we can.”

Coming Monday: The Navigating Aging column will look at the grief faced by long-term care workers as COVID-19 cases and deaths mount.

Join Judith Graham for a Facebook Live event on grief and bereavement during the coronavirus pandemic on Monday, Nov. 16, at 1 p.m. ET. You can watch the conversation here and submit questions in advance here.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Nursing Homes Still See Dangerously Long Waits for COVID Test Results


This story also ran on CNN. It can be republished for free.

Nursing homes are still taking days to get back COVID-19 test results as many shun the Trump administration’s central strategy to limit the spread of the virus among old and sick Americans.

In late summer, federal officials began distributing to nursing homes millions of point-of-care antigen tests, which can be given on-site and report the presence or absence of the virus within minutes. By January, the Department of Health and Human Services is slated to send roughly 23 million rapid tests.

But as of Oct. 25, 38% of the nation’s roughly 15,000 nursing homes have yet to use a point-of-care test, a KHN analysis of nursing home records shows.

The numbers suggest a basic disagreement among the Trump administration, state health officials and nursing home administrators over the best way to test this population and how to strike the right balance between speed and accuracy. Many nursing homes still primarily send samples out to laboratories, using a type of test that’s considered more reliable but can take days to deliver results.

As a result, in 29% of the approximately 13,000 facilities that provided their testing speed to the government, results for residents took an average of three days or more, the analysis found. Just 17% of nursing homes reported their average turnaround time was less than a day, and the remainder tended to get results in one or two days. Wait times for test results of staff members were similar.

Those lags could have devastating consequences, because even one undetected infection can quietly but rapidly trigger a broad outbreak. It’s especially concerning as winter sets in and the pandemic notches daily records of infections.

In the meantime, the coronavirus continues its march through institutions. Nursing homes have reported more than 262,000 infections and 59,000 deaths since the government began collecting the information in May. Even without estimating how many residents died from COVID-19 before then, reported nursing home deaths amount to more than a quarter of all COVID-19 fatalities in the U.S. so far.

During the week ending Oct. 25, the most recent period for which data is available, a third of skilled nursing facilities reported a new suspected or confirmed coronavirus infection of a resident or staff member.

Many state public health authorities and nursing homes have ongoing reservations about the rapid tests. They are considered less accurate than the more expensive ones sent out to laboratories, which are known as polymerase chain reaction, or PCR, tests and identify the virus’s genetic material but often take days to complete. And their manufacturers say the rapid tests are designed for people with symptoms — not for screening a general population.

In early November, the Food and Drug Administration warned of false positive results — where someone is told incorrectly they are infected — associated with one type of rapid COVID test, and urged providers to follow Centers for Disease Control and Prevention recommendations for using them in nursing homes. False negatives are also a concern because people who don’t know they are infected can unwittingly spread the virus.

HHS bought millions of rapid tests to distribute to nursing homes as the federal government imposed new mandates for the facilities to test staffers at least once a month. Routine staff testing increases to as often as twice a week for homes in areas with the highest infection rates. The Centers for Medicare & Medicaid Services, which is part of HHS, does not recommend testing asymptomatic residents unless a new outbreak occurs or a resident routinely goes outside the facility.

Leaders in multiple states, including Nevada, Vermont and Illinois, have moved to ban antigen tests in nursing homes or limit their use.

“I thought the hard part was getting the testing to the different facilities,” said David Grabowski, a health care policy professor at Harvard Medical School. Instead, he said, “The major barriers to the use of rapid testing seem to be a lack of guidance on when and how to use the tests, coupled with concerns about their accuracy.”

Dr. Michael Wasserman, immediate past president of the California Association of Long Term Care Medicine, said the national effort has been chaotic and inadequate.

The federal government “just hands stuff off to nursing homes and then says, ‘Hey, it’s yours; go use it,’” he said. “And then when things fall apart, ‘We’re not to blame.’”

Nursing homes that don’t trust the rapid tests are having to shoulder the higher cost of lab tests. It costs Stuart Almer, president and CEO of Gurwin Jewish Nursing & Rehabilitation Center on New York’s Long Island, $125,000 a week to conduct lab tests on up to 1,500 residents and staff members.

“We embrace the testing,” Almer said. “But how are we supposed to continue operating and paying for this?”

Goodwin House in Virginia, which includes skilled nursing and assisted living facilities, had performed more than 9,500 tests for COVID-19 as of late October, said Joshua Bagley, an administrator. Only 100 of them were antigen tests. “The majority of our focus is still toward the PCR testing,” Bagley said.

The concerns of state health officials were perhaps most evident in Nevada, where in early October the state banned antigen testing in nursing homes. HHS said the order was illegal, and it was revoked within days.

“There is no such thing as a perfect test,” Adm. Brett Giroir, a senior HHS official who leads the Trump administration’s COVID testing efforts, said on a call with reporters Nov. 9. For example, Giroir said, a risk of PCR tests is that they could provide a positive diagnosis when a person is no longer “actually infectious.”

Although there have been widespread accuracy concerns over antigen tests, certain tests the administration is distributing nationwide have comparable accuracy to lab-based tests, he said.

Other state responses have not been as aggressive as Nevada’s but nonetheless demonstrated unease over how best to use the devices, if at all.

Vermont recommends the use of antigen tests after a known COVID exposure but says they should not be used to diagnose asymptomatic people.

Ohio was initially reluctant to deploy them after Republican Gov. Mike DeWine’s false positive result from an antigen device, although the tests have since been adopted, said Peter Van Runkle, executive director of the Ohio Health Care Association, which represents some  skilled nursing facilities in the state.

Some nursing homes say relying on antigen tests has made a monumental difference. In Hutchinson, Kansas, Wesley Towers Retirement Community has used both types of tests, but it was Abbott’s BinaxNOW antigen test that detected its first two asymptomatic people with COVID-19, said Gretchen Sapp, Wesley Towers’ vice president of health services.

“We have more confidence that our staff are indeed COVID free or that they are out and not exposing residents. And that is incredibly helpful,” Sapp said. “The biggest challenge is I need more tests.”

A total of 1,150 homes told the federal government they did not have enough supplies for point-of-care tests for all workers, the KHN analysis found. Nursing homes can go through millions of tests quickly when testing monthly or more often, depending on the level of COVID-19 in the area.

White House spokesperson Michael Bars said the administration is working “hand-in-hand with our state and local partners” and “doing more than ever to protect the health and safety of high-risk age groups most susceptible to the virus.”

Janet Snipes, executive director of Holly Heights Care Center in Denver, said antigen tests have been useful to screen staff members despite a few false-positive results. One test was used on a clergy member a resident had summoned.

“We wouldn’t have been able to allow him in, but we were able to do the antigen testing,” she said. “With the vulnerable residents we serve, we’re hoping for more antigen testing, more testing period, more testing of any type.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Seniors Form COVID Pods to Ward Off Isolation This Winter

Over the past month, Dr. Richard Besdine and his wife have been discussing whether to see family and friends indoors this fall and winter.

He thinks they should, so long as people have been taking strict precautions during the coronavirus pandemic.

She’s not convinced it’s safe, given the heightened risk of viral transmission in indoor spaces.

Both are well positioned to weigh in on the question. Besdine, 80, was the longtime director of the division of geriatrics and palliative medicine at Brown University’s Alpert Medical School. His wife, Terrie Wetle, 73, also an aging specialist, was the founding dean of Brown’s School of Public Health.

“We differ, but I respect her hesitancy, so we don’t argue,” Besdine said.

Older adults in all kinds of circumstances — those living alone and those who are partnered, those in good health and those who are not — are similarly deliberating what to do as days and nights turn chilly and coronavirus cases rise across the country.

Some are forming “bubbles” or “pods”: small groups that agree on pandemic precautions and will see one another in person in the months ahead. Others are planning to go it alone.

Judith Rosenmeier, 84, of Boston, a widow who’s survived three bouts of breast cancer, doesn’t intend to invite friends to her apartment or visit them in theirs.

“My oncologist said when all this started, ‘You really have to stay home more than other people because the treatments you’ve had have destroyed a lot of your immune defenses,’” she said.

Since mid-March, Rosenmeier has been outside only three times: once, in September, to go to the eye doctor and twice since to walk with a few friends. After living in Denmark for most of her adult life, she doesn’t have a lot of close contacts. Her son lives in Edinburgh, Scotland.

“There’s a good chance I’ll be alone on Thanksgiving and on Christmas, but I’ll survive,” she said.

A friend who lives nearby, Joan Doucette, 82, is determined to maintain in-person social contacts. With her husband, Harry Fisher, 84, she’s formed a “pod” with two other couples in her nine-unit apartment building. All are members of Beacon Hill Village, an organization that provides various services to seniors aging in place. Doucette sees her pod almost every day.

“We’re always running up and down the stairs or elevator and bringing each other cookies or soup,” she said. “I don’t think I would have survived this pandemic without that companionship.”

About once a week, the couples have dinner together and “we don’t wear masks,” said Jerry Fielder, 74, who moved to Boston two years ago with his partner, Daniel, 73. But he said he feels safe because “we know where everyone goes and what they do: We’re all on the same page. We go out for walks every day, all of us. Otherwise, we’re very careful.”

Eleanor Weiss, 86, and her husband are also members of the group. “I wear a mask, I socially distance myself, but I don’t isolate myself,” Weiss said. This winter, she said, she’ll see “a few close friends” and three daughters who live in the Boston area.

One daughter is hosting Thanksgiving at her house, and everyone will get tested for the coronavirus beforehand. “We’re all careful. We don’t hug and kiss. We do the elbow thing,” Weiss said.

In Chicago, Arthur Koff, 85, and his wife, Norma, 69, don’t yet have plans for Thanksgiving or Christmas. “It’s up in the air depending on what’s happening with the virus,” he said. The couple has a wide circle of friends.

“I think it’s going to be a very hard winter,” said Koff, who has diabetes and blood cancer. He doesn’t plan to go to restaurants but hopes to meet some friends he trusts inside their homes or apartments when the weather turns bad.

Julie Freestone, 75, and her husband, Rudi Raab, 74, are “pretty fanatic” about staying safe during the pandemic. The couple invited six friends over for “Thanksgiving in October” earlier this month — outside, in their backyard in Richmond, California.

“Instead of a seating chart, this year I had a plating chart and I plated everything in advance,” Freestone said. “I asked everybody to tell me what they wanted — White or dark meat? Brussels sprouts or broccoli?”

This winter, Freestone isn’t planning to see people inside, but she’ll visit with people in groups, virtually. One is her monthly women’s group, which has been getting together over Zoom. “In some ways, I feel we’ve reached a new level of intimacy because people are struggling with so many issues — and we’re all talking about that,” she said.

“I think you need to redefine bubbles,” said Freestone, who’s on the board of Ashby Village, a Berkeley, California-based organization for seniors aging in place that’s hosting lots of virtual groups. “It should be something you feel a part of, but it doesn’t have to be people who come into your house.”

In the Minneapolis-St. Paul area in Minnesota, two psychologists — Leni de Mik, 79, and Brenda Hartman, 65 — are calling attention to what they call SILOS, an acronym for “single individuals left out of social circles,” and their need for dependable social contact this winter and fall.

They recommend that older adults in this situation reach out to others with similar interests — people they may have met at church or in book clubs or art classes, for instance — and try to form a group. Similarly, they recommend that families or friends invite a single older friend into their pods or bubbles.

“Look around at who’s in your community. Who used to come to your house that you haven’t seen? Reach out,” de Mik recommended.

Both psychologists are single and live alone. De Mik’s pod will include two friends who are “super careful outside,” as she is. Hartman’s will include her sister, 67, and her father, 89, who also live alone. Because her daughter works in an elementary school, she’ll see her only outside. Also, she’ll be walking regularly with two friends over the winter.

“COVID brings life and death right up in front of us,” Hartman said, “and when that happens, we have the opportunity to make crucial choices — the opportunity to take care of each other.”

Consumer Resources

Public health experts advise that thorough and frequent hand-washing, wearing masks in public meeting in small groups and maintaining at least 6 feet of social distancing can help prevent the transmission of the coronavirus. The federal Centers for Disease Control and Prevention has more detailed advice on its website, including these pages:

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They Work in Several Nursing Homes to Eke Out a Living, Possibly Spreading the Virus

To make ends meet, Martha Tapia works 64 hours a week at two Orange County, California, nursing homes. She is one of thousands of certified nursing assistants who perform the intimate and physical work of bathing, dressing and feeding the nation’s fragile elderly.

“We do everything for them. Everything you do for yourself, you have to do for the residents,” Tapia said.

And she’s one of many in that low-paid field, predominantly women of color, who work at more than one facility.

In March, when the coronavirus began racing through nursing homes, the federal government banned visitors. (That guidance has since been updated.) But even with the ban, infections kept spreading. A team of researchers from UCLA and Yale University decided to examine the people who continued to enter nursing homes during that time: the employees.

Keith Chen, a behavioral economist and UCLA professor, said the key question is this: “The people who, we can infer, work in this nursing home — what other nursing homes do they work at?”

Using location data from 30 million smartphones when the visitor ban was in place helped the scientists “see” the movements of people going into and out of nursing homes. The data showed a lot of nursing home workers are — like Tapia — working at more than one facility. Chen said the findings suggest that staffers who work in multiple nursing homes are one source of the spread of infections.

“When you learn that over 20 of your workers are also spending time in other nursing homes, that should be a real red flag,” Chen said.

The Toll on Patients and Beyond

More than 84,000 residents and staff members of nursing homes and other long-term care facilities have died of COVID-19 across the U.S., representing 40% of all coronavirus fatalities in the country, according to KFF’s most recent analysis. (KHN is an editorially independent program of KFF.)

In California, the analogous toll is more than 5,700 deaths, making up 35% of all coronavirus fatalities in the state.

The UCLA team created maps of movement and found that on average each nursing home is connected to seven others through staff movement. Limiting nursing home employees to one facility could mean fewer COVID-19 infections — but that would hurt the workforce of people who say they work multiple jobs because of low wages.

After each of her shifts, Tapia worries she’ll bring the coronavirus home to her granddaughter. She tries to take precautions, including buying N95 masks from nurses. She knows it’s not just patients who are at risk. Nursing home workers such as Tapia are also contracting COVID-19 — in California alone, 153 of them have died since the pandemic began.

At the nursing home where she works in the morning, Tapia gets an N95 mask that she must only use — and reuse — in that facility. At her other nursing home job, in the afternoons, she gets a blue surgical mask to wear.

“They say they cannot give us N95 [masks],” she said, because she works in the “general area” where residents haven’t tested positive for the coronavirus.

She doesn’t want to work at multiple nursing homes, but her rent in Orange County is $2,200 a month, and her low pay and limited hours at each nursing home make multiple jobs a necessity.

“I don’t want to get sick. But we need to work. We need to eat, we need to pay rent. That’s just how it is,” Tapia said.

Staff Connections Equal Infections

The UCLA study also found that some areas of the country have a much higher overlap in nursing home staffing than others.

“There are some facilities in Florida, in New Jersey, where they’re sharing upwards of 50 to 100 workers,” said UCLA associate professor Elisa Long, who, along with her colleagues, examined data during the federal visitor ban from March to May. “This is over an 11-week time period, but that’s a huge number of individuals that are moving between these facilities; all of these are potential sources of COVID transmission.”

They also found the more shared workers a nursing home has, the more COVID-19 infections among the residents.

“Not only does it matter how connected your nursing home is, but what really matters is how connected your connections are,” Long said.

The researchers say they’ve informally dubbed these highly connected nursing homes as each state’s “Kevin Bacon of nursing homes,” after the Six Degrees of Kevin Bacon parlor game.

“We found that if you’re going to see a nursing home outbreak anywhere, it’s likely to spread to the Kevin Bacon of nursing homes in each state,” Chen said.

The team hopes that local health departments could use similar cellphone data methods as an early warning system. Using the test results from the “Kevin Bacon of nursing homes” as an indicator would be the first step.

“As soon as you detect an outbreak in one nursing home, you can immediately prioritize those other nursing homes that you know are at increased risk,” Chen said.

Prioritize Masks and Hand-Washing

The California Association of Health Facilities represents most nursing homes in the Golden State. In response to the study, the group said its members can’t prevent workers such as Tapia from taking jobs elsewhere, and they can’t pay them more, because California doesn’t pay them enough through Medicaid reimbursements.

Mike Dark, an attorney with the California Advocates for Nursing Home Reform, doesn’t buy that argument. He said the state already tried paying nursing homes more in 2006 — and that made them more profitable but not more safe and efficient. He said he’s skeptical that extra funding to pay staff would reach those workers.

“We know from past experience that money tends to go into the pockets of the executives and administrators who run these places,” Dark said.

He agreed that health workers such as Tapia should be paid more but cautioned against one idea being floated in some policy circles: limiting workers to one nursing home.

“Then you can wind up depriving some of the crucial health caregivers that we have in these facilities of their livelihoods, which can’t be a good solution,” he said.

Instead, he said, regulators need to focus on the basics, especially in the 100 California nursing homes with ongoing outbreaks, since it’s been shown that infection control measures work.

“Right now there’s poor access to [personal protective equipment]. There’s still erratic compliance with things like hand-washing requirements,” he said. “If we spent more time addressing those key issues, there would be much less concern about spread between facilities.”

Jackie Fortiér is health reporter for KPCC and LAist.com. This story is part of a partnership that includes KPCC, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Despite COVID Concerns, Teams Venture Into Nursing Homes to Get Out the Vote

RALEIGH, N.C. — Each time Beverly Tucker visited a nursing home or long-term care facility this fall, she brought along a rolling tote bag packed with supplies from the Durham County Board of Elections.

Boxes of face masks and face shields. Latex gloves and cleaning wipes. Hand sanitizer from Mystic Farm & Distillery, a local facility that was among the first to switch from producing liquor to hand sanitizer in the early days of the pandemic. And most important — even if they were dwarfed by the cleaning supplies — the absentee ballots and ballot request forms that Tucker would help residents complete in time for the election.

“The equipment is clearly different this year,” Tucker said. “But I’m doing whatever is possible to help people vote.”

Seniors in such facilities across the country have struggled to find safe ways to vote amid the pandemic. In North Carolina, it’s a particular challenge. The state is one of two (the other being Louisiana) where facility staffers are prohibited by law from assisting residents with voting. A 2013 voter ID law makes it a felony for staff to even sign as the witness on an absentee ballot.

That’s where community members like Tucker come in. The 66-year-old Durham resident is a member of the county’s multipartisan assistance team, often called a MAT, which helps residents in nursing homes, assisted living and other facilities complete mail-in or absentee ballots. The teams are appointed by the county board of elections and must include at least two people who have different political party affiliations or are unaffiliated. Some counties pay the teams, while others ask members to volunteer.

This year, the convergence of coronavirus concerns and the election has unexpectedly thrust team members to the front lines. They are entering some of the state’s hardest-hit sites, with nursing home residents accounting for about 40% of North Carolina’s COVID deaths, as cases continue to rise. The added risk has disrupted this crucial system in some areas. At least one county was unable to recruit a team, and members in another county have been unwilling to visit facilities with documented COVID cases.

But those who do venture inside say the risk is worth it to help people vote.

Kevin Marr, 66, has been volunteering with the voting assistance team in Wake County since 2017. He recognizes many of the residents now, even behind their masks. Although the visits are different this year, he said the residents’ enthusiasm to vote and receive their “I Voted” stickers is not. That’s what keeps him going, visiting about two facilities a day in recent weeks.

Tucker, of neighboring Durham County, has worked in public health for decades, including during the AIDS epidemic. She understood it was safer to go to residents in nursing homes and long-term care facilities than to risk them coming to polling sites with more people.

Still, when she first thought about holding voters’ hands to help them grasp a pen or sign a ballot, “I was instinctively reluctant to touch them,” she said. At the first nursing home Tucker visited, she felt anxious as a resident approached her without a mask.

But her concerns have eased over time, she said, and she simply focuses on ways to protect herself and her team. They conduct most of the visits outdoors, in the parking lot or front lawn. They put up plexiglass barriers between themselves and the voters, passing papers through an opening at the bottom. And they now carry masks for residents who may not have one.

It’s difficult to maintain social distancing when one team member is working with a resident to mark a ballot and the other is observing to ensure accuracy, but they do their best.

Foreseeing these challenges, the North Carolina Board of Elections asked the state legislature and courts earlier this year to temporarily suspend restrictions on facility staff assisting with voting. But neither request was fulfilled. A recent lawsuit contesting the restriction won accommodations for the plaintiff, who was a nursing home resident, but left the broader law intact.

At Brian Center Health and Rehabilitation in Goldsboro, administrator Julia Batts worried that MAT members would not be allowed to visit, since the facility has a designated COVID-positive unit with about a dozen residents. But when statewide visitation regulations eased in September, she eagerly reached out to them.

The plan was careful and clinical. Have the team set up in the dining hall of the COVID-free building and bring in any residents who had tested negative to meet with them, two at a time, in alphabetical order.

But on the day the team arrived, it felt more like a celebration. Several women asked the staff to do their hair, and many residents “began wheeling themselves or taking their walkers to go vote,” Batts said. “They were almost racing.”

By the end of the day, the team helped about 20 residents vote. They’ll return next week to assist more residents, including new entrants who finished their two-week quarantine and those who have recovered from COVID, Batts said.

For Linda Williamson in Durham County, seeing the enthusiasm of voters reminds her of her grandparents. They took her along when they cast their first ballot in the 1960s, after African Americans won the right to vote. The then-9-year-old Williamson dressed in her Sunday best: hair ribbons and patent-leather shoes. As she watched her grandparents disappear behind the voting curtain, she couldn’t wait for it to be her turn someday.

This year, she couldn’t bear to think that nursing home and assisted-living residents — many of whom likely fought for their right to vote just like her grandparents — would be robbed of that opportunity.

So Williamson, 64, put her apprehension about COVID aside, donned her face mask and gloves, and visited five facilities this fall.

To each resident she’d say, “Gosh, you picked a great day to vote.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Older COVID Patients Battle ‘Brain Fog,’ Weakness and Emotional Turmoil

“Lord, give me back my memory.”

For months, as Marilyn Walters has struggled to recover from COVID-19, she has repeated this prayer day and night.

Like other older adults who’ve become critically ill from the coronavirus, Walters, 65, describes what she calls “brain fog” — difficulty putting thoughts together, problems with concentration, the inability to remember what happened a short time before.

This sudden cognitive dysfunction is a common concern for seniors who’ve survived a serious bout of COVID-19.

“Many older patients are having trouble organizing themselves and planning what they need to do to get through the day,” said Dr. Zijian Chen, medical director of the Center for Post-COVID Care at Mount Sinai Health System in New York City. “They’re reporting that they’ve become more and more forgetful.”

Other challenges abound: overcoming muscle and nerve damage, improving breathing, adapting to new impairments, regaining strength and stamina, and coping with the emotional toll of unexpected illness.

Most seniors survive COVID-19 and will encounter these concerns to varying degrees. Even among the age group at greatest risk — people 85 and older — just 28% of those with confirmed cases end up dying, according to data from the Centers for Disease Control and Prevention. (Because of gaps in testing, the actual death rate may be lower.)

Walters, who lives in Indianapolis, spent almost three weeks in March and April heavily sedated, on a ventilator, fighting for her life in intensive care. Today, she said, “I still get tired real easy and I can’t breathe sometimes. If I’m walking sometimes my legs get wobbly and my arms get like jelly.”

“Emotionally, it’s been hard because I’ve always been able to do for myself, and I can’t do that as I like. I’ve been really nervous and jittery,” Walters said.

Younger adults who’ve survived a serious course of COVID-19 experience similar issues but older adults tend to have “more severe symptoms, and more limitations in terms of what they can do,” Chen said.

“Recovery will be on the order of months and years, not days or weeks,” said Dr. E. Wesley Ely, co-director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University Medical Center. Most likely, he speculated, a year after fighting the disease at least half of the critically ill older patients will not have fully recovered.

The aftereffects of delirium — an acute, sudden change of consciousness and mental acuity — can complicate recovery from COVID-19. Seniors hospitalized for serious illness are susceptible to the often-unrecognized condition when they’re immobilized for a long time, isolated from family and friends, and given sedatives to ease agitation or narcotics for pain, among other contributing factors.

In older adults, delirium is associated with a heightened risk of losing independence, developing dementia and dying. It can manifest as acute confusion and agitation or as uncharacteristic unresponsiveness and lethargy.

“What we’re seeing with COVID-19 and older adults are rates of delirium in the 70% to 80% range,” said Dr. Babar Khan, associate director of Indiana University’s Center for Aging Research at the Regenstrief Institute, and one of Walters’ physicians.

Gordon Quinn, 77, a Chicago documentary filmmaker, believes he contracted COVID-19 at a conference in Australia in early March. At Northwestern Memorial Hospital, he was put on a ventilator twice in the ICU, for a total of nearly two weeks, and remembers having “a lot of hallucinations” — a symptom of delirium.

“I remember vividly believing I was in purgatory. I was paralyzed — I couldn’t move. I could hear snatches of TV — reruns of ‘Law & Order: Special Victims Unit’ — and I asked myself, ‘Is this my life for eternity?’” Quinn said.

Given the extent of delirium and mounting evidence of neurological damage from COVID-19, Khan said he expects to see “an increased prevalence of ICU-acquired cognitive impairment in older COVID patients.”

Ely agrees. “These patients will urgently need to work on recovery,” he said. Family members should insist on securing rehabilitation services — physical therapy, occupational therapy, speech therapy, cognitive rehabilitation — after the patient leaves the hospital and returns home, he advised.

“Even at my age, people can get incredible benefit from rehab,” said Quinn, who spent nearly two weeks at Chicago’s Shirley Ryan AbilityLab, a rehabilitation hospital, before returning home and getting several weeks of home-based therapy. Today, he’s able to walk nearly 2 miles and has returned to work, feeling almost back to normal.

James Talaganis, 72, of Indian Head Park, Illinois, also benefited from rehab at Shirley Ryan AbilityLab after spending nearly four months in various hospitals beginning in early May.

Talaganis had a complicated case of COVID-19: His kidneys failed and he was put on dialysis. He experienced cardiac arrest and was in a coma for almost 58 days while on a ventilator. He had intestinal bleeding, requiring multiple blood transfusions, and was found to have crystallization and fibrosis in his lungs.

When Talaganis began his rehab on Aug. 22, he said, “my whole body, my muscles were atrophied. I couldn’t get out of bed or go to the toilet. I was getting fed through a tube. I couldn’t eat solid foods.”

In early October, after getting hours of therapy each day, Talaganis was able to walk 660 feet in six minutes and eat whatever he wanted. “My recovery — it’s a miracle. Every day I feel better,” he said.

Unfortunately, rehabilitation needs for most older adults are often overlooked. Notably, a recent study found that one-third of critically ill older adults who survive a stay in the ICU did not receive rehab services at home after hospital discharge.

“Seniors who live in more rural areas or outside bigger cities where major hospital systems are providing cutting-edge services are at significant risk of losing out on this potentially restorative care,” said Dr. Sean Smith, an associate professor of physical medicine and rehabilitation at the University of Michigan.

Sometimes what’s most needed for recovery from critical illness is human connection. That was true for Tom and Virginia Stevens of Nashville, Tennessee, in their late 80s, who were both hospitalized with COVID-19 in early August.

Ely, one of their physicians, found them in separate hospital rooms, frightened and miserable. “I’m worried about my husband,” he said Virginia told him. “Where am I? What is happening? Where is my wife?” the doctor said Tom asked, before crying out, “I have to get out of here.”

Ely and another physician taking care of the couple agreed. Being isolated from each other was dangerous for this couple, married for 66 years. They needed to be put in a room together.

When the doctor walked into their new room the next day, he said, “it was a night-and-day difference.” The couple was sipping coffee, eating and laughing on beds that had been pushed together.

“They both got better from that point on. I know that was because of the loving touch, being together,” Ely said.

That doesn’t mean recovery has been easy. Virginia and Tom still struggle with confusion, fatigue, weakness and anxiety after their two-week stay in the hospital, followed by two weeks in inpatient rehabilitation. Now, they’re in a new assisted living residence, which is allowing outdoor visits with their family.

“Doctors have told us it will take a long time and they may never get back to where they were before COVID,” said their daughter, Karen Kreager, also of Nashville. “But that’s OK. I’m just so grateful that they came through this and we get to spend more time with them.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Pandemic Erects Barriers for Prized Bloc of Voters in Nursing Homes, Senior Facilities

The convergence of the coronavirus pandemic and election season has complicated this year’s voting for residents of nursing homes, assisted living facilities and other long-term care centers.

Many seniors who need help to get or fill out their ballots may be stymied by shifting rules about family visits. Voting procedures — whether in person or by mail — are under increased scrutiny, adding to the confusion. Facilities that used to host voting precincts likely won’t do so this year because of concerns about the spread of COVID-19.

“We’re basically not allowed to go out into the public right now, we’re more vulnerable, and our immune systems are compromised anyway,” said Janice Phillips, a 14-year resident of Village Square Healthcare Center, a skilled nursing facility in San Marcos, California. “We’re basically locked in.”

Phillips, 75, who has rheumatoid arthritis, has voted by absentee ballot for years without problems. This year she is encouraging her fellow residents to vote by mail as well. She works with the facility’s activities staff, going resident by resident, to make sure folks are registered. As president of the resident council, Phillips has also raised the issue at community meetings.

Older Americans are a consistent voting bloc courted by both parties.

According to AARP, 71% of Americans 65 and older voted in the 2016 presidential election, compared with 46% of people 18-29. “For many older adults, it’s a point of pride for them that they’ve voted in every election since they were 18,” said Leza Coleman, the executive director of California’s Long-Term Care Ombudsman Association.

But hardly anyone has been allowed inside skilled nursing facilities since the start of the pandemic, except for staff members and the occasional state health official, or family members in certain circumstances. In California and beyond, facilities are beginning to open up in counties with low transmission rates, since federal rules changed in September to allow for more lenient visiting policies.

At the same time, outbreaks continue to plague some senior facilities, despite improved testing of staff and other safety measures. On Wednesday, Santa Cruz County health officials reported a major outbreak at the Watsonville Post-Acute Center, which has infected 46 residents, killing nine of them, and infecting 15 staff members.

California officials are pressing nursing homes and senior centers to give residents who want to vote the opportunity. The Department of Public Health on Oct. 5 sent a letter to all those facilities, explaining they have an obligation to inform and assist residents with voting, including what actions are permissible for staffers to undertake in helping voters. It also includes advice about maintaining a safe environment through the election by limiting nonessential visitors, properly using protective gear such as gloves and handling ballots as little as possible.

In years past, civic groups such as the League of Women Voters would stop by to give presentations on what’s on the ballot. Candidates for local office would hit nursing homes to make pitches. “In the context of a pandemic, we just can’t do it this year,” said Michelle Bishop, voter access and engagement manager with the National Disability Rights Network.

Before the pandemic, nursing homes and assisted living facilities also often served as polling places. Residents could easily access voting booths, often set up in a lobby or community room. That was especially important because nursing homes are likely to be accessible to people with mobility problems, Bishop said.

Otherwise, facilities would often organize bus trips and outings to polling places.

In California, the last day to register to vote online or by mail is Oct. 19, though voters can register in person up to and including Election Day. All registered voters will receive a ballot in the mail, and those postmarked by Nov. 3 will still be counted in California for 17 days after the election. Advocates say it’s important for newer residents at skilled nursing facilities to make sure they’ve registered at their new address or have plans to get their ballot delivered to them from their former homes.

Other states are also sending ballots to all registered voters by mail this year on various time frames. All states permit seniors or people who have trouble reaching polling stations to request an absentee ballot.

Once they have a ballot in hand, some older adults need help from family or staff at their facilities to complete it correctly and send it back to election officials. The federal directive to relax visiting rules could ease some of that pressure, but the situation varies by facility. For people whose relatives cannot help them, it may fall to staff members to set up calls and video chats between residents and their families, or provide the assistance to residents themselves.

Some states don’t allow nursing home staffers to help with ballots to avoid influencing votes. Even if they can assist, employees may be stretched too thin to help. In a year when nursing home staff members are spending an extra hour each day putting on protective gear, there isn’t always extra time to make sure every resident is registered and voting, said Dr. Karl Steinberg, chief medical officer for Mariner Health Central, a nursing home management company in California.

“There’s a perennial workforce shortage in nursing homes and it’s been exacerbated by this” pandemic, Steinberg said. “This year with all the chaos, there may be less staff time available to help people with voting.”

Tracy Greene Mintz, whose business, Senior Care Training, trains senior care workers, is responsible for staffing at 100 nursing homes in California. She said she started ringing alarm bells about voting rights in August.

“Elected officials do not care about nursing homes, period,” Greene Mintz said. “They assume residents don’t vote and don’t make contributions.”

She asked the California Department of Public Health, which surveys skilled nursing facilities every six weeks about COVID-19 infection control, to add a question on how facilities were planning for elections. The department declined.

So she set up webinars with facility administrators and the Los Angeles County Registrar-Recorder/County Clerk to go over information on how to submit and track absentee ballots.

She has also urged state officials to provide a statewide plan that facilities could use as a blueprint. She wrote one herself that was emailed out by a trade group, the California Association of Health Facilities.

Still, California is in better shape than some other states, said Raúl Macías, a lawyer with the Democracy Program at the Brennan Center for Justice, a law and public policy institute. Elsewhere, residents may have to apply for an absentee ballot, and sometimes must provide a reason they can’t vote in person.

California also has the Voter Bill of Rights, which allows individuals to designate someone to help them fill out and drop off their ballot. In some states, such as North Carolina, assistance can come only from designated bipartisan voting assistance teams, which may be harder to recruit during a pandemic, Macías said.

No matter the state, state and county elections officials and facility administrators should draft voting plans, said Bishop, of the Disabilities Rights Network. It will help staff know the proper way to assist residents without influencing their votes, and residents know their voting rights.

“There is a bit of a gray area on whose responsibility this is,” Bishop said. “It’s one of the years when we start asking ‘Whose responsibility is it?’ Who cares? We have to get it done.”

If they can’t get access to ballots or need help, California residents can contact the state’s long-term care ombudsman program, which can investigate complaints, help them resolve the issue and take the problem to the Department of Public Health if it can’t be fixed.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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How to Treat Polycystic Ovary Syndrome (PCOS) with Diet

Given the role that oxidant free radicals are thought to play in aging and disease, one reason fruits and vegetables may be so good for us is that they contain antioxidant compounds. As you can see at 0:20 in my video Benefits of Marjoram for Polycystic Ovary Syndrome (PCOS), different vegetables and herbs have different antioxidant content. When making a salad, for example, spinach, arugula, or red leaf lettuce may provide twice the antioxidants as butterhead lettuce, and choosing purple cabbage over green, or red onions over white can also boost the salad’s antioxidant power.

Fresh herbs are so powerful that even a small amount may double or even quadruple the antioxidant power of the entire meal. For instance, as you can see at 0:50 in my video, the total antioxidants in a simple salad of lettuce and tomato jump up by adding just a tablespoon of lemon balm leaves or half a tablespoon of oregano or mint. Adding marjoram, thyme, or sage not only adds great flavor to the salad, but effectively quadruples the antioxidant content at the same time, and adding a little fresh garlic or ginger to the dressing ups the antioxidant power even more.

Herbs are so antioxidant-rich that researchers decided to see if they might be able to reduce the DNA-damaging effects of radiation. Radioactive iodine is sometimes given to people with overactive thyroid glands or thyroid cancer to destroy part of the gland or take care of any remaining tumor cells after surgery. For days after the isotope injection, patients become so radioactive they are advised not to kiss or sleep close to anyone, including their pets, and if they breathe on a phone, they’re advised to wipe it “carefully” or cover it “with an easily removed plastic bag.” Other recommendations include “avoid[ing] splatter of radioactive urine,” not going near your kids, and basically just staying away from others as much as possible.

The treatment can be very effective, but all that radiation exposure appears to increase the risk of developing new cancers later on. In order to prevent the DNA damage associated with this treatment, researchers tested the ability of oregano to protect chromosomes of human blood cells in vitro from exposure to radioactive iodine. As you can see at 2:25 in my video, at baseline, about 1 in 100 of our blood cells show evidence of chromosomal damage. If radioactive iodine is added, though, it’s more like 1 in 8. What happens if, in addition to the radiation, increasing amounts of oregano extract are added? Chromosome damage is reduced by as much 70 percent. Researchers concluded that oregano extract “significantly protects” against DNA damage induced by the radioactive iodine in white blood cells. This was all done outside the body, though, which the researchers justified by saying it wouldn’t be particularly ethical to irradiate people for experimental research. True, but millions of people have been irradiated for treatment, and researchers could have studied them or, at the very least, they could have just had people eat the oregano and then irradiate their blood in vitro to model the amount of oregano compounds that actually make it into the bloodstream.

Other in vitro studies on oregano are similarly unsatisfying. In a comparison of the effects of various spice extracts, including bay leaves, fennel, lavender, oregano, paprika, parsley, rosemary, and thyme, oregano beat out all but bay leaves in its ability to suppress cervical cancer cell growth in vitro while leaving normal cells alone. But people tend to use oregano orally—that is, they typically eat it—so the relevance of these results are not clear.

Similarly, marjoram, an herb closely related to oregano, can suppress the growth of individual breast cancer cells in a petri dish, as you can see at 3:53 in my video, and even effectively whole human breast tumors grown in chicken eggs, which is something I’ve never seen before. Are there any clinical trials on oregano-family herbs on actual people? The only such clinical, randomized, control study I could find was a study on how marjoram tea affects the hormonal profile of women with polycystic ovary syndrome (PCOS). The most common cause of female fertility problems, PCOS affects up to one in eight young women and is characterized by excessive male hormones, resulting in excess body or facial hair, menstrual irregularities, and cysts in one’s ovaries that show up on ultrasounds.

Evidently, traditional medicine practitioners reported marjoram tea was beneficial for PCOS, but it had never been put to the test…until now. Drinking two daily cups of marjoram tea versus a placebo tea for one month did seem to beneficially affect the subjects’ hormonal profiles, which seems to offer credence to the claims of the traditional medicine practitioners. However, the study didn’t last long enough to confirm that actual symptoms improved as well, which is really what we care about.

Is there anything that’s been shown to help? Well, reducing one’s intake of dietary glycotoxins may help prevent and treat the disease. Over the past 2 decades there has been increasing evidence supporting an important contribution from food-derived advanced glycation end products (AGEs)…[to] increased oxidative stress and inflammation, processes that play a major role in the causation of chronic diseases,” potentially including polycystic ovary syndrome (PCOS). Women with PCOS tend to have nearly twice the circulating AGE levels in their bloodstream, as you can see at 0:33 in my video Best Foods for Polycystic Ovary Syndrome (PCOS). 

PCOS may be the most common hormonal abnormality among young women in the United States and is a common cause of infertility, menstrual dysfunction, and excess facial and body hair. The prevalence of obesity is also higher in women with PCOS. Since the highest AGE levels are found in broiled, grilled, fried, and roasted foods of “mostly animal origin,” is it possible that this causal chain starts with a bad diet? For instance, maybe eating lots of fried chicken leads to obesity, which in turn leads to PCOS. In that case, perhaps what we eat is only indirectly related to PCOS through weight gain. No, because the same link between high AGE levels and PCOS was found in lean women as well.

“As chronic inflammation and increased oxidative stress have been incriminated in the pathophysiology [or disease process] of PCOS, the role of AGEs as inflammatory and oxidant mediators, may be linked with the metabolic and reproductive abnormalities of the syndrome.” Further, the buildup of AGE inside polycystic ovaries themselves suggests a potential role of AGEs contributing to the actual disease process, beyond just some of its consequences.

RAGE is highly expressed in ovarian tissues. The receptor in the body for these advanced glycation end products, the “R” in RAGE, is concentrated in the ovaries, which may be particularly sensitive to its effect. So, AGEs might indeed be contributing to the cause of PCOS and infertility.

Does this mean we should just cut down on AGE-rich foods, such as meat, cheese, and eggs? Or hey, why not come up with drugs that block AGE absorption? We know AGEs have been implicated in the development of many chronic diseases. Specifically, food-derived AGEs play an important role because diet is a major source of these pro-inflammatory AGEs. Indeed, cutting down on these dietary glycotoxins reduces the inflammatory response, but the “argument is often made that stewed chicken would be less tasty than fried chicken…” Why not have your KFC and eat it, too? Just take an AGE-absorption blocking drug every time you eat it to reduce the absorption of the toxins. What’s more, it actually lowers AGE blood levels. This oral absorbent drug, AST-120, is just a preparation of activated charcoal, like what’s used for drug overdoses and when people are poisoned. I’m sure if you took some ipecac with your KFC, your levels would go down, too.

There’s another way to reduce absorption of AGEs, and that’s by reducing your intake in the first place. It’s simple, safe, and feasible. The first step is to stop smoking. The glycotoxins in cigarette smoke may contribute to increased heart disease and cancer in smokers. Then, decrease your intake of high-AGE foods, increase your intake of foods that may help pull AGEs out of your system, like mushrooms, and eat foods high in antioxidants, like berries, herbs, and spices. “Dietary AGE intake can be easily decreased by simply changing the method of cooking from a high dry heat application to a low heat and high humidity…” In other words, move away from broiling, searing, and frying to more stewing, steaming, and boiling.

What we eat, however, may be more important than how we cook it. At 4:00 in my video, I include a table showing the amounts of AGEs in various foods. For instance, boiled chicken contains less than half the glycotoxins of roasted chicken, but even deep-fried potatoes have less than boiled meat. We can also eat foods raw, which doesn’t work as well as for blood pudding, but raw nuts and nut butters may contain about 30 times less glycotoxins than roasted, and we can avoid high-AGE processed foods, like puffed, shredded, and flaked breakfast cereals.

Why does it matter? Because study after study has shown that switching to a low-AGE diet can lower the inflammation within our bodies. Even just a single meal high in AGEs can profoundly impair our arterial function within just two hours of consumption. At 4:54 in my video, you can see the difference between a meal of fried or broiled chicken breast and veggies compared with steamed or boiled chicken breast and veggies. Same ingredients, just different cooking methods. Even a steamed or boiled chicken meal can still impair arterial function, but significantly less than fried or broiled.

“Interestingly, the amount of AGEs administered [to subjects] during the HAGE [high-AGE] intervention was similar to the average estimated daily intake by the general population,” who typically follow the standard American diet. This is why we can decrease inflammation in people by putting them on a low-AGE diet, yet an increase in inflammation is less apparent when subjects switch from their regular diet to one high in AGEs. Indeed, they were already eating a high-AGE diet with so many of these glycotoxins.

Do we have evidence that reducing AGE intake actually helps with PCOS? Yes. Within just two months, researchers found differences from subjects’ baseline diets switched to a high-AGE diet and then to a low-AGE diet, with parallel changes in insulin sensitivity, oxidative stress, and hormonal status, as seen at 5:54 in my video. The take-home learning? Those with PCOS may want to try a low-AGE diet, which, in the study, meant restricting meat to once a week and eating it only boiled, poached, stewed, or steamed, as well as cutting out fast-food-type fare and soda.

What if instead of eating steamed chicken, we ate no meat at all? Rather than measuring blood levels, which vary with each meal, we can measure the level of glycotoxins stuck in our body tissues over time with a high-tech device that measures the amount of light our skin gives off because AGEs are fluorescent. And, not surprisingly, this turns out to be a strong predictor of overall mortality. So, the lower our levels, the better. The “one factor that was consistently associated with reduced [skin fluorescence]: a vegetarian diet.” This “suggests that a vegetarian diet may reduce exposure to preformed dietary AGE…potentially reduc[ing] tissue AGE,” as well as chronic disease risk


What’s so great about antioxidants? See my videos:

Just how many antioxidants do we need? Check out:

For a few simple tips on how to quickly boost the antioxidant content of your food with herbs and spices, see my video Antioxidants in a Pinch.

I touched on the benefits of spearmint tea for PCOS in Enhancing Athletic Performance with Peppermint. Another sorely under-recognized gynecological issue is endometriosis, which I discuss in How to Treat Endometriosis with Seaweed.

Because of AGEs, I no longer toast nuts or buy roasted nut butters, which is disappointing because I really enjoy those flavors so much more than untoasted and unroasted nuts. But, as Dr. McDougall likes to say, nothing tastes as good as healthy feels. For more on why it’s important to minimize our exposure to these toxic compounds, see:

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

 

 

Lifetime Experiences Help Older Adults Build Resilience to Pandemic Trauma

Older adults are especially vulnerable physically during the coronavirus pandemic. But they’re also notably resilient psychologically, calling upon a lifetime of experience and perspective to help them through difficult times.

New research calls attention to this little-remarked-upon resilience as well as significant challenges for older adults as the pandemic stretches on. It shows that many seniors have changed behaviors — reaching out to family and friends, pursuing hobbies, exercising, participating in faith communities — as they strive to stay safe from the coronavirus.

“There are some older adults who are doing quite well during the pandemic and have actually expanded their social networks and activities,” said Brian Carpenter, a professor of psychological and brain sciences at Washington University in St. Louis. “But you don’t hear about them because the pandemic narrative reinforces stereotypes of older adults as frail, disabled and dependent.”

Whether those coping strategies will prove effective as the pandemic lingers, however, is an open question.

“In other circumstances — hurricanes, fires, earthquakes, terrorist attacks — older adults have been shown to have a lot of resilience to trauma,” said Sarah Lowe, an assistant professor at Yale University School of Public Health who studies the mental health effects of traumatic events.

“But COVID-19 is distinctive from other disasters because of its constellation of stressors, geographic spread and protracted duration,” she continued. “And older adults are now cut off from many of the social and psychological resources that enable resilience because of their heightened risk.”

The most salient risk is of severe illness and death: 80% of COVID-19 deaths have occurred in people 65 and older.

Here are notable findings from a new wave of research documenting the early experiences of older adults during the pandemic:

Changing behaviors. Older adults have listened to public health authorities and taken steps to minimize the risk of being infected with COVID-19, according to a new study in The Gerontologist.

Results come from a survey of 1,272 adults age 64 and older administered online between May 4 and May 17. More than 80% of the respondents lived in New Jersey, an early pandemic hot spot. Blacks and Hispanics — as well as seniors with lower incomes and in poor health — were underrepresented.

These seniors reported spending less face-to-face time with family and friends (95%), limiting trips to the grocery store (94%), canceling plans to attend a celebration (88%), saying no to out-of-town trips (88%), not going to funerals (72%), going to public places less often (72%) and canceling doctors’ appointments (69%).

Safeguarding well-being. In another new study published in The Gerontologist, Brenda Whitehead, an associate professor of psychology at the University of Michigan-Dearborn, addresses how older adults have adjusted to altered routines and physical distancing.

Her data comes from an online survey of 825 adults age 60 and older on March 22 and 23 — another sample weighted toward whites and people with higher incomes.

Instead of inquiring about “coping” — a term that can carry negative connotations — Whitehead asked about sources of joy and comfort during the pandemic. Most commonly reported were connecting with family and friends (31.6%), interacting on digital platforms (video chats, emails, social media, texts — 22%), engaging in hobbies (19%), being with pets (19%), spending time with spouses or partners (15%) and relying on faith (11.5%).

“In terms of how these findings relate to where we are now, I would argue these sources of joy and comfort, these coping resources, are even more important” as stress related to the pandemic persists, Whitehead said.

Maintaining meaningful connections with older adults remains crucial, she said. “Don’t assume that people are OK,” she advised families and friends. “Check in with them. Ask how they’re doing.”

Coping with stress. What are the most significant sources of stress that older adults are experiencing? In Whitehead’s survey, older adults most often mentioned dealing with mandated restrictions and the resulting confinement (13%), concern for others’ health and well-being (12%), feelings of loneliness and social isolation (12%), and uncertainty about the future of the pandemic and its impact (9%).

Keep in mind, older adults expressed these attitudes at the start of the pandemic. Answers might differ now. And the longer stress endures, the more likely it is to adversely affect both physical and mental health.

Managing distress. The COVID-19 Coping Study, a research effort by a team at the University of Michigan’s Institute for Social Research, offers an early look at the pandemic’s psychological impact.

Results come from an online survey of 6,938 adults age 55 and older in April and May. Researchers are following up with 4,211 respondents monthly to track changes in older adults’ responses to the pandemic over a year.

Among the key findings published to date: 64% of older adults said they were extremely or moderately worried about the pandemic. Thirty-two percent reported symptoms of depression, while 29% reported serious anxiety.

Notably, these types of distress were about twice as common among 55- to 64-year-olds as among those 75 and older. This is consistent with research showing that people become better able to regulate their emotions and manage stress as they advance through later life.

On the positive side, older adults are responding by getting exercise, going outside, altering routines, practicing self-care, and adjusting attitudes via meditation and mindfulness, among other practices, the study found.

“It’s important to focus on the things we can control and recognize that we do still have agency to change things,” said Lindsay Kobayashi, a co-author of the study and assistant professor of epidemiology at the University of Michigan School of Public Health.

Addressing loneliness. The growing burden of social isolation and loneliness in the older population is dramatically evident in new results from the University of Michigan’s National Poll on Healthy Aging, with 2,074 respondents from 50 to 80 years old. (It found that, in June, twice as many older adults (56%) felt isolated from other people as in October 2018 (27%).

Although most reported using social media (70%) and video chats (57%) to stay connected with family and friends during the pandemic, they indicated this didn’t alleviate feelings of isolation.

“What I take from this is it’s important to find ways for older adults to interact face to face with other people in safe ways,” said Dr. Preeti Malani, chief health officer at the University of Michigan. “Back in March, April and May, Zoom family time was great. But you can’t live in that virtual universe forever.”

“A lot of well-intentioned families are staying away from their parents because they don’t want to expose them to risk,” Malani continued. “But we’re at a point where risks can be mitigated, with careful planning. Masks help a lot. Social distancing is essential. Getting tested can be useful.”

Malani practices what she preaches: Each weekend, she and her husband take their children to see her elderly in-laws or parents. Both couples live less than an hour away.

“We do it carefully — outdoors, physically distant, no hugs,” Malani said. “But I make a point to visit with them because the harms of isolation are just too high.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Topical Lemon Balm Lotion for Alzheimer’s

Improving cognitive performance with aromatherapy in young, healthy volunteers is one thing, but how about where it really matters? As I discuss in my video Best Aromatherapy Herb for Alzheimer’s, a group of Japanese researchers had a pie-in-the-sky notion that certain smells could lead to “nerve rebirth” in Alzheimer’s patients. Twenty years ago, even simply raising such a possibility as a hypothetical was heretical. Everybody knew that the loss of neurons is irreversible. In other words, dead nerve cells are not replaced, an important factor in neurodegenerative diseases. That’s what I was taught and what everyone was taught, until 1998.

Patients with advanced cancer volunteered to be injected with a special dye that’s incorporated into the DNA of new cells. On autopsy, researchers then went hunting for nerve cells that lit up in the brains. And, as you can see at 1:14 in my video, there they were: new nerve cells in the brain that didn’t exist just days or months before, demonstrating “that cell genesis occurs in human brains and that the human brain retains the potential for self-renewal throughout life”—something in which we can take comfort.

It still doesn’t mean smells can help, though. An aromatherapy regimen of rosemary, lemon, lavender, and orange essential oils was attempted for a month. At 1:43 in my video, you can see the trajectory of the subjects’ cognitive function and their ability to form abstract ideas starting six weeks before the treatment. Prior to the aromatherapy regimen, there was a rather steady decline, which was reversed after the aromatherapy. The researchers concluded that aromatherapy may be efficacious and “have some potential for improving cognitive function, especially in AD [Alzheimer’s disease] patients”—all, of course, without any apparent side effects.

What about severe dementia? We always hear about the cognitive deficits, but more than half of patients with dementia experience behavioral or psychiatric symptoms. Thorazine-type antipsychotic drugs are often prescribed, even though they appear to be particularly dangerous in the elderly. “Antipsychotic medication may be viewed as an easier option than non pharmacological alternatives,” such as aromatherapy. Another study examined the effect of rubbing a lemon balm-infused lotion on the arms and face of patients twice daily by caregiving staff, compared with lotion without the scent. “During the 4 weeks, significant improvements were seen” in agitation, shouting, screaming, and physical aggression, as were improved quality of life indicators, with patients less socially withdrawn and more engaged in constructive activities, compared to the unscented control. This is important because antipsychotics cause patients to become more withdrawn and less engaged. They are like a chemical restraint. The drugs can reduce agitation, too. So, aromatherapy with lemon balm “is safe, well tolerated, and highly efficacious, with additional benefits on key quality of life parameters.”

These findings clearly indicate the need for longer-term multicenter trials,” but we never had any, until…never. We still don’t have any. This study was conducted in 2002, and there have been no follow-ups. Is that a surprise? Who’s going to fund such a study: Big Balm?

I’ve produced one other video on lemon balm: Reducing Radiation Damage with Ginger and Lemon Balm. We grow lemon balm in our garden. It makes a delicious tea. Give it a try!


For more on the potential (and limitations) of aromatherapy, check out:

It’s better, of course, to prevent dementia in the first place. Learn more:

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

Is Cuomo Directive to Blame for Nursing Home COVID Deaths, as US Official Claims?

On the first night of the Democratic National Convention, New York Gov. Andrew Cuomo was among the first in a weeklong parade of speakers to issue scathing critiques of the Trump administration’s coronavirus response.

Cuomo’s criticisms drew a quick reply in a tweet from Michael Caputo, an assistant secretary for public affairs at the Department of Health and Human Services.

“Does the #DemConvention know @NYGovCuomo forced nursing homes across NY to take in COVID positive patients and planted the seeds of infection that killed thousands of grandmothers and grandfathers?” he wrote.

It was an easy jab: Cuomo has been dogged by criticism for months over his March advisory directing nursing homes in the state to accept patients who had or were suspected of having COVID-19. As long as they were medically stable, the notice said, it was appropriate to move patients in. Further, nursing homes were prohibited from requiring that medically stable prospective residents be tested for the virus before they arrived.

Between March 25 and May 8, approximately 6,326 COVID-positive patients were admitted to nursing homes, according to a state health department report.

While experts say this policy was flawed, is it fair to say that the governor’s directive “forced” nursing homes to take patients who were sick with COVID-19? And to what extent did that strategy sow the seeds of disease and death? When we examined the evidence, we found it was less clear-cut than the statement makes it seem. The policy likely had an effect, but epidemiologists identified additional factors that fed the problem. What’s more, the policy did not “force” nursing homes to accept COVID-positive patients. Nursing homes interpreted it this way.

We checked with HHS to find the basis for Caputo’s comment but got no response.

The Back Story

As the virus tore through nursing homes, killing dozens at some of them, Cuomo came under withering censure. His administration’s policy, implemented with an eye toward freeing up hospital beds for an onslaught of COVID patients, seemed to disregard the risks to frail and elderly nursing home residents who were especially vulnerable to the disease.

According to the COVID Tracking Project, 6,624 people have died of COVID-19 in nursing homes and other long-term care facilities in New York, accounting for 26% of the state’s 25,275 COVID deaths. Some say the true number of deaths is much higher because, unlike many states, New York does not count the deaths of former nursing home residents who are transferred to hospitals and die there as nursing home deaths.

Cuomo’s explanation for the policy — that he was simply following guidance from the federal Centers for Disease Control and Prevention — didn’t cut it. A recent PolitiFact piece examining his claim rated it “Mostly False.”

In May, the governor amended the March order, prohibiting hospitals from discharging patients to nursing homes unless they tested negative for COVID-19.

A Misguided Approach

In the early days of the COVID-19 pandemic, when New York was the epicenter and more than a thousand people were being hospitalized daily, there was a genuine fear that hospitals would not be able to accommodate the influx of desperately ill patients.

Moving people out of the hospitals and into nursing homes was one strategy to help hospitals meet these needs.

According to the CDC guidance cited in the earlier PolitiFact story, there were two factors to consider when deciding whether to discharge a patient with COVID-19 to a long-term care facility: whether the patient was medically ready, and whether the facility could implement the recommended infection-control procedures to safely care for a patient recovering from the virus.

A document from the federal Centers for Medicare & Medicaid Services said nursing homes should accept only patients they were able to care for.

Long-standing state guidance is based on the same condition.

Still, nursing homes didn’t believe turning away patients with COVID-19 was an option.

“On its face, it looked like a requirement,” said Christopher Laxton, executive director of the Society for Post-Acute and Long-Term Care Medicine, which represents medical professionals in nursing homes and other long-term care facilities. “The nursing homes we spoke to felt it was a mandate, and a number of them felt they had no choice but to take COVID patients.”

While the overarching guidance not to take patients in unless they could be safely cared for may have been clear, nursing homes’ experience was often different, said.

Richard Mollot, executive director of the Long-Term Care Community Coalition, an advocacy group for elderly and disabled people. “There was little reason for nursing homes to think they should only take in patients if they have the ability to do so safely because those rules are not generally enforced on a regular basis.”

Bottom line: State and federal rules didn’t force nursing homes to accept COVID-positive patients, but many of them believed they had no other choice.

A Lethal Result?

How much of the blame for the deaths of thousands of people in nursing homes from COVID-19 can be attributed to Cuomo’s March advisory?

That is the 6,000-person question.

In a July analysis of COVID-19 nursing home deaths, the state concluded that the deadly virus was introduced by nursing home staff members rather than sick patients.

It noted that peak nursing home resident mortality from COVID-19 on April 8 preceded the peak influx of COVID patients on April 14. In addition, it found that nearly 1 in 4 nursing home workers — 37,500 people — were infected with the virus between March and early June.

Based on these and other factors, the report concluded that the state admissions policy could not have been a driver of nursing home infections or fatalities.

Epidemiologists and nursing home advocates beg to differ.

“To say that introducing patients [to nursing homes] who had COVID did not cause problems is ridiculous,” said Laxton.

Calling the study’s approach “pretty flawed,” Denis Nash, an epidemiologist at City University of New York School of Public Health, said he didn’t agree with the report’s conclusion that the policy had nothing to do with deaths.

Others had the same view. “I didn’t think they showed data to say [the policy] is not a ‘driver,’” said Rupak Shivakoti, an assistant professor of epidemiology at the Mailman School of Public Health at Columbia University.

But Gary Holmes, assistant commissioner at the New York State Department of Health, had a different take. Critics of the report, he said, must be deliberately ignoring the rising death tolls in nursing homes in hot spots across the country.

“Public health officials in those states are experiencing (and acknowledging) what NY’s report indicated weeks ago: these facilities are microcosms of the community and transmission is occurring unknowingly by asymptomatic spread among staff members,” Holmes said, in an email.

While public health experts quibbled with the report’s self-serving claim that the governor’s policy wasn’t a factor in COVID-19 nursing home deaths, they nevertheless agreed with the report’s broader conclusion that nursing home staffers as well as visitors, before they were banned, were likely the main drivers of COVID-19 infection and death in nursing homes.

“Based on the timeline of the policy and deaths in the city, it is very unlikely that policy contributed to thousands of deaths,” said Shivakoti.

Infection control is a long-standing problem at nursing homes, Nash said, and the COVID deaths were a basic failure of infection control. That said, “it’s unclear how many of the deaths the policy might have caused.”

Also unclear: how many of the dead were grandmothers and grandfathers.

Our Ruling

In a tweet, the HHS assistant secretary for public affairs said that New York Gov. Andrew Cuomo “forced” nursing homes across the state to admit COVID-positive patients and that this policy fueled the spread of COVID-19 that led to thousands of deaths in the nursing home population.

Although nursing homes felt pressure to accept COVID-positive patients, they were not actually forced to do so. State regulations require nursing homes to accept patients only if they can care for them, and they could have refused them on those grounds.

In addition, it’s unclear the extent to which the governor’s policy was responsible for nursing home COVID-19 deaths. Infection control is a long-standing problem in nursing homes, predating the pandemic, and a report showed peak numbers of nursing home deaths came prior to the peak influx of patients as a result of Cuomo’s advisory. While the introduction of COVID-19 positive patients into nursing homes no doubt had an effect on infection spread, Caputo’s statement suggests it was solely responsible. That’s not what the evidence shows.

We rate this Mostly False.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Trump Is Sending Fast, Cheap COVID Tests to Nursing Homes — But There’s a Hitch

The Trump administration’s latest effort to use COVID-19 rapid tests — touted by one senior official as a “turning point” in arresting the coronavirus’s spread within nursing homes — is running into roadblocks likely to limit how widely they’ll be used.

Federal officials are distributing point-of-care antigen tests — which are cheaper and faster than tests that must be run by a lab — to 14,000 nursing homes to increase routine screening of residents and staff. The initial distribution targets nursing homes in hot spots and those with at least three COVID-19 cases, senior Trump administration officials said in July, hailing it as a tool that could root out asymptomatic carriers who might still infect others.

But there’s a hitch: Two manufacturers that have received Food and Drug Administration authorization and whose instruments are being delivered — Becton, Dickinson and Co., known as BD, and Quidel — say their antigen tests are intended for patients with symptoms, calling into question how valuable the tests would be for broad screening purposes. The Centers for Disease Control and Prevention estimates 40% of infected people may be asymptomatic.

“It’s important always to use a diagnostic in the way that it has been designed to be used,” said Elizabeth Talbot, New Hampshire’s deputy state epidemiologist. “We simply don’t know how [the tests] will perform in persons who are asymptomatic.”

Perhaps the highest-profile example of the problem occurred in Ohio this month, when Gov. Mike DeWine had no symptoms and tested positive for COVID-19 with Quidel’s antigen test. Within hours, the Republican governor’s diagnosis was reversed after he got a PCR test.

“People should not take away from my experience that testing is not reliable or doesn’t work,” DeWine said on CNN after his false-positive diagnosis. “The antigen tests are fairly new,” he said. “We’re going to be very careful in how we use it.”

The bigger problem is false-negative results, which show someone isn’t infected when they actually are. BD’s false-negative rate — how often a test incorrectly says someone isn’t infected — is about 15%; Quidel’s is 3%.

Quidel and BD say their tests are intended to be used for people within the first five days of showing symptoms. A spokesperson for BD said its test should not be used on asymptomatic individuals. Quidel through a spokesperson deferred to FDA guidelines, which allow asymptomatic testing in certain scenarios.

“For routine surveillance, this is a great tool and these are our best tools that we have available,” said Adm. Brett Giroir, assistant secretary for health at the Department of Health and Human Services, on a July call with nursing home officials, according to a recording obtained by KHN. Seema Verma, the administrator of the federal Centers for Medicare & Medicaid Services, on the call referred to the effort as a “turning point” in the fight against the virus.

A month after the initial announcement, the Trump administration invoked the Defense Production Act to bump its contracts with the two companies to the front of the line and expedite shipments. BD will send roughly 11,000 devices and 3.75 million tests to nursing homes; Quidel and HHS declined to answer questions about its volume.

As states and the federal government move to mandate COVID testing inside nursing homes, whose patients are deemed highly vulnerable to infection and severe complications, several industry officials have said they hoped to use the tests on asymptomatic people. But many states restrict the use of antigen tests or still require lab-based testing because of accuracy concerns.

If a person with a negative test result has to default to getting a more accurate PCR test, “then we simply have just added time and cost,” Talbot said. “That’s a problem.”

Officials said the antigen test announcement caught them by surprise, underscoring the administration’s chaotic testing strategy. Separate from the federal effort, 10 states have banded together through the Rockefeller Foundation to secure 5 million tests from the two companies in hopes of curbing the virus’s spread this fall.

After nursing homes receive an initial batch of tests — each facility gets between 150 and 900 — they would have to buy future supplies. Medicare will cover the costs of diagnostic tests but not expenses for routine surveillance.

“I just have a lot of skepticism,” said Brendan Williams, president of the New Hampshire Health Care Association, which represents nursing homes and assisted living facilities in the state. “Basically you’re giving some lousy tests for nursing homes and you’re making them pay for them. I don’t see that as a win; I see that as a risk.”

Public health experts have become increasingly vocal that frequent rapid testing is the best tool for stopping the virus — which has killed more than 174,000 Americans including tens of thousands in nursing care — rather than relying on more accurate lab-based tests that have been plagued by delays and shortages. In a call this month with the industry, Verma estimated that half of the country’s nursing homes have experienced cases.

“I don’t see an avenue where these will not help to stop transmission chains, and I don’t see another option on the table for us,” said Dr. Michael Mina, an assistant professor of epidemiology at the Harvard T.H. Chan School of Public Health and a proponent of rapid tests. “It is what we need to be doing right now.”

“This is better for the folks in our buildings, without a doubt,” added Jason Belden, director of emergency preparedness and physical plant services for the California Association of Health Facilities.

In theory, antigen tests can serve dual purposes — diagnosing a person with a suspected infection or screening a group of people to more quickly identify sick individuals. The tests by Quidel and BD, under their FDA authorizations, can be used on certain asymptomatic individuals, including those suspected of having COVID-19 after exposure to an infected person. The companies would need additional FDA authorization to screen any asymptomatic person regardless of whether they’re suspected of being sick, according to agency guidelines.

The CDC has suggested antigen tests could be useful in high-risk settings if performed repeatedly. It said there was limited data to guide using them to screen asymptomatic people.

Nonetheless, HHS recommends universal screening of nursing home residents at least once and regular screening of staff regardless of symptoms, said agency spokesperson Mia Heck, citing the fact that COVID-19 viral loads are similar between patients with and without symptoms. “Only one test in the U.S. is authorized for asymptomatic individuals,” she said, referring to a PCR test from LabCorp, “yet the overwhelming majority of testing is being done on asymptomatic individuals.”

“If the world were ideal we’d say, ‘Oh, we want the more accurate test.’ But the more accurate test takes forever to get the results back,” said Peter Van Runkle, executive director of the Ohio Health Care Association, which represents the state’s nursing homes.

All targeted nursing homes will receive tests by the end of September, according to federal officials, who recently announced that facilities in states with a positivity rate of at least 5% must test staff each week.

“I don’t see this as a federal strategy so much as a stopgap method to bring a little relief to nursing homes,” said Katie Smith Sloan, president of LeadingAge, which represents nonprofit nursing homes. “It’s really tragic that we are where we are right now.”

Boosted by $71 million in federal funds for Quidel and $24.3 million for BD, Quidel plans to produce 1.8 million tests weekly by September; BD will produce similar volumes by October.

“The situation is much too urgent to wait a few months so we can put bows and lipstick on the program. So we’re going to build this plane a little bit while we’re flying it,” Giroir told nursing homes in July. “Just work with us. We want to get you what you need. And then in September, October you can get what you want.”

States take different approaches in deploying antigen tests in nursing homes; in at least seven — including California, Illinois and Maryland — officials say PCR tests should still be used to confirm results or to screen patients without symptoms. In Massachusetts, nursing homes must use PCR tests to meet surveillance requirements.

In Maryland, “our goal is to screen out staff who are positive as quickly as possible, particularly asymptomatic folks,” said Dennis Schrader, chief operating officer of the health department.

Maryland nursing homes can use antigen tests for weekly staff testing if there isn’t an outbreak. But if at least one person tests positive for the coronavirus, all staff and residents must be tested with PCR tests.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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We Put Off Planning, Until My Father-in-Law’s Medical Crisis Took Us by Surprise

Earlier this month, my husband picked up the phone and learned his 92-year-old father had been taken to the hospital that morning, feeling sick and short of breath.

We were nearly 2,000 miles away, on a vacation in the mountains of southern Colorado.

No, it wasn’t COVID-19. My father-in-law, Mel, who has diabetes, high blood pressure and kidney disease, was suffering from fluid buildup in his legs and around his lungs and excruciating knee pain. Intravenous medications and steroid injections were administered, and he responded well.

Doctors monitored Mel carefully, adjusted his medications and recommended a few weeks of home health care after eight days in the hospital.

In other words, this was not a life-threatening emergency. Yet we realized how poorly prepared we were for a real crisis, should one arise. We needed a plan.

Why didn’t we have one already? The usual reasons: denial, avoidance and wishful thinking. It was easier to imagine that Mel would be all right until it became clear that we couldn’t take that for granted.

Although I routinely advise readers about preparing for changes in their health, I didn’t want to be a know-it-all with my husband’s family. Their assumption seemed to be “We’ll deal with whatever comes up when that happens.”

Now, eyes wide open, we got organized.

Some background: Mel lives in a well-run continuing care retirement community in upstate New York, in the independent living section. His three sons all live at a distance: one out West, one overseas and one a few hours away.

Hiring a care manager. Last year, as Mel’s kidney function declined, I suggested we hire a geriatric care manager who could look in on him regularly. After a few visits, Mel let her go. Her services were too expensive, he complained. In truth, we understood, he didn’t want someone interfering in his affairs.

My husband respects his father’s autonomy and didn’t press the point.

So, when Mel went to the hospital a few weeks ago, he was alone, with no one to turn to for assistance.

This was especially problematic because Mel has hearing loss and it is almost impossible to talk with him by phone. “How are you, Dad?” my husband yelled on twice-a-day calls to check on his father in the hospital. “What?” Mel replied querulously. This was repeated a few times, with mounting frustration and no useful information exchanged.

Now a care manager who could serve as our eyes and ears on the ground was necessary, not optional, and we hired back the professional we’d already found.

Finding companion care. What kind of assistance was Mel going to need when he left the hospital, deconditioned and weaker than when he went in?

When we spoke with the physician overseeing Mel’s care in the hospital, he suggested that “companion care” for at least a few weeks would be a good idea. Mel needed someone to help him up out of the chair, stay at his side while he walked to the bathroom and bring him a glass of water, among other tasks. (Also, we realized, we needed to arrange for meals to be delivered to Mel and for someone from his senior community to buy groceries for him — a service they’d started during the pandemic.)

An excellent organization that works with older adults in Mel’s area supplied me with a list of 21 agencies that provide these kinds of services — a dizzying array of choices.

Fortunately, the senior community where Mel lives recommended an agency that often works with its residents. We hired 24/7 care for several days after Mel left the hospital with the understanding that we’d continue services if necessary. Now, this agency is on our list of essential resources.

Understanding the options. Mel’s senior community incorporates assisted living and a nursing home for residents who need short-term rehabilitation services or longer-term round-the-clock care.

But it was clear Mel wanted to go home after being in the hospital instead of going to that rehab. Medicare would pay for a few weeks of visits from nurses and physical and occupational therapists. Would that be enough to set him on the road to recovery? We had no idea.

If Mel couldn’t return to his previous level of functioning after returning home, he might need to transition to assisted living, where he could receive more medical oversight and assistance. How would this work? We didn’t know and asked the geriatric care manager to find out.

Getting paperwork in order. Years ago, Mel assigned power of attorney for his health care decisions and financial and legal affairs to my husband. So long as Mel can manage on his own, he makes his own decisions: The legal papers were a backup arrangement.

But Mel hadn’t prepared a document naming all three sons as his “personal representatives” under the Health Insurance Portability and Accountability Act of 1996. This waives privacy concerns and gives them access to his medical information. It went on our “to-do” list.

The brothers also didn’t have a complete list of Mel’s doctors, the medications he was on and why he was taking them. Another item for our list, especially important since Mel left the hospital with prescriptions for 14 medications, several of them new. While he’d always managed on his own before, in his post-hospital fog it was clear he was nervous about managing this complicated regimen.

Understanding the prognosis. Before Mel’s hospitalization, we knew his kidney function was worsening. But what lay ahead? Was dialysis even an option for a 92-year-old in this time of COVID-19?

Who was best prepared to help us understand Mel’s prognosis and the big picture?

I’ve written for years about geriatricians’ comprehensive approach to the health of older adults. It turns out, there’s a top-notch group of geriatricians affiliated with the hospital where Mel was being treated.

After several calls, I reached one who agreed to see Mel after he was released from the hospital. Now, we have another new team member who can help us understand Mel’s health trajectory and issues that might arise going forward.

Having the conversation. What has yet to happen is the conversation that my husband hasn’t wanted to have. “Dad, if your health takes a turn for the worse again, what do you want? What’s most important to you? What does quality of life mean to you? And what can we do to help?”

With Mel’s hearing problems, doing this over the phone won’t do.

My husband would have to fly cross-country and, ideally, meet his New York brother at Mel’s place for a conversation of this kind. Before that happens, the brothers should talk among themselves. What’s their understanding of what Mel wants? Are they on the same page?

Also, no one has discussed financial arrangements.

Each time we explain to Mel one of the new services we’ve arranged, his first question is “What’s the cost?” His impulse is to guard his cherished savings and not to spend. My husband tells him he shouldn’t worry, but this, too, is a conversation that has to happen.

Being prepared. Professionally, I know a lot about the kinds of problems families encounter when an older relative becomes ill. Personally, I’ve learned that families don’t really understand what’s involved until they go through it on their own.

Now, Mel has a new set of supports in place that should help him weather the period ahead. And my husband is keenly aware that planning doesn’t stop here. He’ll be attending to his father far more carefully going forward.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Isolation, Disruption and Confusion: Coping With Dementia During a Pandemic

GARDENA, Calif. — Daisy Conant, 91, thrives off routine.

One of her favorites is reading the newspaper with her morning coffee. But, lately, the news surrounding the coronavirus pandemic has been more agitating than pleasurable. “We’re dropping like flies,” she said one recent morning, throwing her hands up.

“She gets fearful,” explained her grandson Erik Hayhurst, 27. “I sort of have to pull her back and walk her through the facts.”

Conant hasn’t been diagnosed with dementia, but her family has a history of Alzheimer’s. She had been living independently in her home of 60 years, but Hayhurst decided to move in with her in 2018 after she showed clear signs of memory loss and fell repeatedly.

For a while, Conant remained active, meeting up with friends and neighbors to walk around her neighborhood, attend church and visit the corner market. Hayhurst, a project management consultant, juggled caregiving with his job.

Then COVID-19 came, wrecking Conant’s routine and isolating her from friends and loved ones. Hayhurst has had to remake his life, too. He suddenly became his grandmother’s only caregiver — other family members can visit only from the lawn.

After their walk, Daisy Conant and her grandson rest in front of their home in Gardena, California. (Heidi de Marco/KHN)

The coronavirus has upended the lives of dementia patients and their caregivers. Adult day care programs, memory cafes and support groups have shut down or moved online, providing less help for caregivers and less social and mental stimulation for patients. Fear of spreading the virus limits in-person visits from friends and family.

These changes have disrupted long-standing routines that millions of people with dementia rely on to help maintain health and happiness, making life harder on them and their caregivers.

“The pandemic has been devastating to older adults and their families when they are unable to see each other and provide practical and emotional support,” said Lynn Friss Feinberg, a senior strategic policy adviser at AARP Public Policy Institute.

Nearly 6 million Americans age 65 and older have Alzheimer’s disease, the most common type of dementia. An estimated 70% of them live in the community, primarily in traditional home settings, according to the Alzheimer’s Association 2020 Facts and Figures journal.

People with dementia, particularly those in the advanced stages of the disease, live in the moment, said Sandy Markwood, CEO of the National Association of Area Agencies on Aging. They may not understand why family members aren’t visiting or, when they do, don’t come into the house, she added.

“Visitation under the current restrictions, such as a drive-by or window visit, can actually result in more confusion,” Markwood said.

Daisy Conant and grandson Erik Hayhurst chat with a family friend on a Zoom call. Hayhurst is using Zoom to keep his grandmother connected to family and friends. (Heidi de Marco/KHN)

The burden of helping patients cope with these changes often falls on the more than 16 million people who provide unpaid care for people with Alzheimer’s or other dementias in the United States.

The Alzheimer’s Association’s 24-hour Helpline has seen a shift in the type of assistance requested during the pandemic. Callers need more emotional support, their situations are more complex, and there’s a greater “heaviness” to the calls, said Susan Howland, programs director for the Alzheimer’s Association California Southland Chapter.

“So many [callers] are seeking advice on how to address gaps in care,” said Beth Kallmyer, the association’s vice president of care and support. “Others are simply feeling overwhelmed and just need someone to reassure them.”

Because many activities that bolstered dementia patients and their caregivers have been canceled due to physical-distancing requirements, dementia and caregiver support organizations are expanding or trying other strategies, such as virtual wellness activities, check-in calls from nurses and online caregiver support groups. EngAGED, an online resource center for older adults, maintains a directory of innovative programs developed since the onset of the COVID-19 pandemic.

They include pen pal services and letter-writing campaigns, robotic pets and weekly online choir rehearsals.

Gina Moran helps her mother, who was diagnosed with Alzheimer’s in 2007, put on her mask. Gina Moran sometimes has trouble getting her mother to wear the mask. (Heidi de Marco/KHN)

Alba Moran must be reminded about the coronavirus pandemic when she is asked to wear her mask. (Heidi de Marco/KHN)

Hayhurst has experienced some rocky moments during the pandemic.

For instance, he said, it was hard for Conant to understand why she needed to wear a mask. Eventually, he made it part of the routine when they leave the house on daily walks, and Conant has even learned to put on her mask without prompting.

“At first it was a challenge,” Hayhurst said. “She knows it’s part of the ritual now.”

People with dementia can become agitated when being taught new things, said Dr. Lon Schneider, director of the Alzheimer’s Disease Research Center at the University of Southern California. To reduce distress, he said, caregivers should enforce mask-wearing only when necessary.

That was a lesson Gina Moran of Fountain Valley, California, learned early on. Moran, 43, cares for her 85-year-old mother, Alba Moran, who was diagnosed with Alzheimer’s in 2007.

“I try to use the same words every time,” Moran said. “I tell her there’s a virus going around that’s killing a lot of people, especially the elderly. And she’ll respond, ‘Oh, I’m at that age.’”

If Moran forgets to explain the need for a mask or social distancing, her mother gets combative. She raises her voice and refuses to listen to Moran, much like a child throwing a tantrum, Moran said. “I can’t go into more information than that because she won’t understand,” she said. “I try to keep it simple.”

The pandemic is also exacerbating feelings of isolation and loneliness, and not just for people with dementia, said Dr. Jin Hui Joo, associate professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. “Caregivers are lonely, too.”

When stay-at-home orders first came down in March, Hayhurst’s grandmother repeatedly said she felt lonesome, he recalled. “The lack of interaction has made her feel far more isolated,” he said.

To keep her connected with family and friends, he regularly sets up Zoom calls.

But Conant struggles with the concept of seeing familiar faces through the computer screen. During a Zoom call on her birthday last month, Conant tried to cut pieces of cake for her guests.

Moran also feels isolated, in part because she’s getting less help from family. In addition to caring for her mom, Moran studies sociology online and is in the process of adopting 1-year-old Viviana.

Right now, to minimize her mother’s exposure to the virus, Moran’s sister is the only person who visits a couple of times a week.

“She stays with my mom and baby so I can get some sleep,” Moran said.

Before COVID, she used to get out more on her own. Losing that bit of free time makes her feel lonely and sad, she admitted.

“I would get my nails done, run errands by myself and go out on lunch dates with friends,” Moran said. “But not anymore.”

Gina Moran juggles several roles. She is the full-time caregiver to both her mother and baby, and studies sociology online. (Heidi de Marco/KHN)


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Bereaved Families Are ‘the Secondary Victims of COVID-19’

Every day, the nation is reminded of COVID-19’s ongoing impact as new death counts are published. What is not well documented is the toll on family members.

New research suggests the damage is enormous. For every person who dies of COVID-19, nine close family members are affected, researchers estimate based on complex demographic calculations and data about the coronavirus.

Many survivors will be shaken by the circumstances under which loved ones pass away — rapid declines, sudden deaths and an inability to be there at the end — and worrisome ripple effects may linger for years, researchers warn.

If 190,000 Americans die from COVID complications by the end of August, as some models suggest, 1.7 million Americans will be grieving close family members, according to the study. Most likely to perish are grandparents, followed by parents, siblings, spouses and children.

“There’s a narrative out there that COVID-19 affects mostly older adults,” said Ashton Verdery, a co-author of the study and a professor of sociology and demography at Pennsylvania State University. “Our results highlight that these are not completely socially isolated people that no one cares about. They are integrally connected with their families, and their deaths will have a broad reach.”

Because of family structures, Black families will lose slightly more close family members than white families, aggravating the pandemic’s disproportionate impact on African American communities. (Verdery’s previous research modeled kinship structures for the U.S. population, dating to 1880 and extending to 2060.)

The potential consequences of these losses are deeply concerning, with many families losing important sources of financial, social and caregiving support. “The vast scale of COVID-19 bereavement has the potential to lower educational achievement among youth, disrupt marriages, and lead to poorer physical and mental health across all age groups,” Verdery and his co-authors observe in their paper.

Holly Prigerson, co-director of the Center for Research on End-of-Life Care at Weill Cornell Medicine in New York City, sounds a similar alarm, especially about the psychological impact of the pandemic, in a new paper on bereavement.

“Bereaved individuals have become the secondary victims of COVID-19, reporting severe symptoms of traumatic stress, including helplessness, horror, anxiety, sadness, anger, guilt, and regret, all of which magnify their grief,” she and co-authors from Memorial Sloan Kettering Cancer Center in New York noted.

In a phone conversation, Prigerson predicted that people experiencing bereavement will suffer worse outcomes because of lockdowns and social isolation during the pandemic. She warned that older adults are especially vulnerable.

“Not being there in a loved one’s time of need, not being able to communicate with family members in a natural way, not being able to say goodbye, not participating in normal rituals — all this makes bereavement more difficult and prolonged grief disorder and post-traumatic stress more likely,” she noted.

Organizations that offer bereavement care are seeing this unfold as they expand services to meet escalating needs.

Typically, 5% to 10% of bereaved family members have a “trauma response,” but that has “increased exponentially — approaching the 40% range — because we’re living in a crisis,” said Yelena Zatulovsky, vice president of patient experience at Seasons Hospice & Palliative Care, the nation’s fifth-largest hospice provider.

Since March, Seasons has doubled the number of grief support groups it offers to 29, hosted on virtual platforms, most of them weekly. All are free and open to community members, not just families whose loved ones received care from Seasons. (To find a virtual group in your time zone, call 1-855-812-1136, Season’s 24/7 call center.)

“We’re noticing that grief reactions are far more intense and challenging,” Zatulovsky said, noting that requests for individual and family counseling have also risen.

Medicare requires hospices to offer bereavement services to family members for up to 13 months after a client’s death. Many hospices expanded these services to community members before the pandemic, and Edo Banach, president and CEO of the National Hospice and Palliative Care Organization, hopes that trend continues.

“It’s not just the people who die on hospice and their families who need bereavement support at this time; it’s entire communities,” he said. “We have a responsibility to do even more than what we normally do.”

In New York City, the center of the pandemic in its early months, the Jewish Board is training school administrators, teachers, counselors and other clinicians to recognize signs of grief and bereavement and provide assistance. The health and human services organization serves New Yorkers regardless of religious affiliation.

“There is a collective grief experience that we are all experiencing, and we’re seeing the need go through the roof,” said Marilyn Jacob, a senior director who oversees the organization’s bereavement services, which now includes two support groups for people who have lost someone to COVID-19.

“There’s so much loss now, on so many different levels, that even very seasoned therapists are saying, ‘I don’t really know how to do this,’” Jacob said. In addition to losing family members, people are losing jobs, friends, routines, social interactions and a sense of normalcy and safety.

For many people, these losses are sudden and unexpected, which can complicate grief, said Patti Anewalt, director of Pathways Center for Grief & Loss in Lancaster, Pennsylvania, affiliated with the state’s largest not-for-profit hospice. The center recently created a four-week group on sudden loss to address its unique challenges.

The day before Julie Cheng’s 88-year-old mother was rushed to the hospital in early July, she had been singing songs with Cheng’s sister over the phone at her Irvine, California, nursing home. The next morning, a nurse reported that the older woman had a fever and was wheezing badly. At the hospital, COVID-19 was diagnosed and convalescent plasma therapy tried. Within two weeks, after suffering a series of strokes, Cheng’s mother died.

Since then, Cheng has mentally replayed the family’s decision not to take her mother out of the nursing home and to refuse mechanical ventilation at the hospital — something she was sure her mother would not have wanted.

“There have been a lot of ‘what ifs?’ and some anger: Someone or something needs to be blamed for what happened,” she said, describing mixed emotions that followed her mother’s death.

But acceptance has sprung from religious conviction. “Mostly, because of our faith in Jesus, we believe that God was ready to take her and she’s in a much better place now.”

Coping with grief, especially when it is complicated by social isolation and trauma, takes time. If you are looking for help, call a local hospice’s bereavement department and ask what kind of services it provides to people in the community. Funeral directors should also have a list of counselors and grief support programs. One option is GriefShare, offered by churches across the country.

Many experts believe the need for these kinds of services will expand exponentially as more family members emerge from pandemic-inspired shock and denial.

“I firmly believe we’re still at the tip of the iceberg, in terms of the help people need, and we won’t understand the full scope of that for another six to nine months,” said Diane Snyder-Cowan, leader of the bereavement professionals steering committee of the National Council of Hospice and Palliative Professionals.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Pandemic Hampers Reopening of Joint Replacement Gold Mine

Dr. Ira Weintraub, a recently retired orthopedic surgeon who now works at a medical billing consultancy, saw a hip replacement bill for over $400,000 earlier this year.

“The patient stayed in the hospital 17 days, which is only 17 times normal. The bill got paid,” mused Weintraub, chief medical officer of Portland, Oregon-based WellRithms, which helps self-funded employers and workers’ compensation insurers make sense of large, complex medical bills and ensure they pay the fair amount.

Charges like that go a long way toward explaining why hospitals are eager to restore joint replacements to pre-COVID levels as quickly as possible — an eagerness tempered only by safety concerns amid a resurgence of the coronavirus in some regions of the country. Revenue losses at hospitals and outpatient surgery centers may have exceeded $5 billion from canceled knee and hip replacements alone during a roughly two-month hiatus on elective procedures earlier this year.

The cost of joint replacement surgery varies widely — though, on average, it is in the tens, not hundreds, of thousands of dollars. Still, given the high and rapidly growing volume, it’s easy to see why joint replacement operations have become a vital chunk of revenue at most U.S. hospitals.

The rate of knee and hip replacements more than doubled from 2000 to 2015, according to inpatient discharge data from the Agency for Healthcare Research and Quality. And that growth is likely to continue: Knee replacements are expected to triple between now and 2040, with hip replacements not far behind, according to projections published last year in the Journal of Rheumatology.

Joint procedures are usually not emergencies, and they were among the first to be scrubbed or delayed when hospitals froze elective surgeries in March — and again in July in some areas plagued by renewed COVID outbreaks. Loss of the revenue has hit hospitals hard, and regaining it will be crucial to their financial convalescence.

“Without orthopedic volumes returning to something near their pre-pandemic levels, it will make it difficult for health systems to get back to anywhere near break-even from a bottom-line perspective,” said Stephen Thome, a principal in health care consulting at Grant Thornton, an advisory, audit and tax firm.

It’s impossible to know exactly how much knee and hip replacements are worth to hospitals, because no definitive data on total volume or price exists.

But using published estimates of volume, extrapolating average commercial payments from published Medicare rates based on a study, and making an educated guess of patient coinsurance, Thome helped KHN arrive at an annual market value for American hospitals and surgery centers of between $15.5 billion and $21.5 billion for knee replacements alone.

That suggests a revenue loss of $1.3 billion to $1.8 billion per month for the period the surgeries were shut down. These figures include ambulatory surgery centers not owned by hospitals, which also suspended most operations in late March, all of April and into May.

If you add hip replacements, which account for about half the volume of knees and are paid at similar rates, the total annual value rises to a range of $23 billion to $32 billion, with monthly revenue losses from $1.9 billion to $2.7 billion.

The American Hospital Association projects total revenue lost at U.S. hospitals will reach $323 billion by year’s end, not counting additional losses from surgeries canceled during the current coronavirus spike. That amount is partially offset by $69 billion in federal relief dollars hospitals have received so far, according to the association. The California Hospital Association puts the net revenue loss for hospitals in that state at about $10.5 billion, said spokesperson Jan Emerson-Shea.

Hospitals resumed joint replacement surgeries in early to mid-May, with the timing and ramp-up speed varying by region and hospital. Some hospitals restored volume quickly; others took a more cautious route and continue to lose revenue. Still others have had to shut down again.

At the NYU Langone Orthopedic Hospital in New York City, “people are starting to come in and you see the operating rooms full again,” said Dr. Claudette Lajam, chief orthopedic safety officer.

At St. Jude Medical Center in Fullerton, California, where the coronavirus is raging, inpatient joint replacements resumed in the second or third week of May — cautiously at first, but volume is “very close to pre-pandemic levels at this point,” said Dr. Kevin Khajavi, chairman of the hospital’s orthopedic surgery department. However, “we are constantly monitoring the situation to determine if we have to scale back once again,” he said.

In large swaths of Texas, elective surgeries were once again suspended in July because of the COVID-19 resurgence. The same is true at many hospitals in Florida, Alabama, South Carolina and Nevada.

The Mayo Clinic in Phoenix suspended nonemergency joint replacement surgeries in early July. It resumed outpatient replacement procedures the week of July 27, but still has not resumed nonemergency inpatient procedures, said Dr. Mark Spangehl, an orthopedic surgeon there. In terms of medical urgency, joint replacements are “at the bottom of the totem pole,” Spangehl said.

In terms of cash flow, however, joint replacements are decidedly not at the bottom of the totem pole. They have become a cash cow as the number of patients undergoing them has skyrocketed in recent decades.

The volume is being driven by an aging population, an epidemic of obesity and a significant rise in the number of younger people replacing joints worn out by years of sports and exercise.

It’s also being driven by the cash. Once only done in hospitals, the operations are now increasingly performed at ambulatory surgery centers — especially on younger, healthier patients who don’t require hospitalization.

The surgery centers are often physician-owned, but private equity groups such as Bain Capital and KKR & Co. have taken an interest in them, drawn by their high growth potential, robust financial returns and ability to offer competitive prices.

“[G]enerally the savings should be very good — but I do see a lot of outlier surgery centers where they are charging exorbitant amounts of money — $100,000 wouldn’t be too much,” said WellRithm’s Weintraub, who co-owned such a surgery center in Portland.

After canceling his hip replacement surgery in March because of COVID-19, Matthew Davis overcame his concerns and rescheduled in June because the procedure was performed at an outpatient surgery center, which meant no overnight hospital stay. (Matthew Davis)

Fear of catching the coronavirus in a hospital is reinforcing the outpatient trend. Matthew Davis, a 58-year-old resident of Washington, D.C., was scheduled for a hip replacement on March 30 but got cold feet because of COVID-19, and canceled just before all elective surgeries were halted. When it came time to reschedule in June, he overcame his reservations in large part because the surgeon planned to perform the procedure at a free-standing surgery center.

“That was key to me — avoiding an overnight hospital stay to minimize my exposure,” Davis said. “These joint replacements are almost industrial-scale. They are cranking out joint replacements 9 to 5. I went in at 6:30 a.m. and I was walking out the door at 11:30.”

Acutely aware of the financial benefits, hospitals and surgery clinics have been marketing joint replacements for years, competing for coveted rankings and running ads that show healthy aging people, all smiles, engaged in vigorous activity.

However, a 2014 study concluded that one-third of knee replacements were not warranted, mainly because the symptoms of the patients were not severe enough to justify the procedures.

“The whole marketing of health care is so manipulative to the consuming public,” said Lisa McGiffert, a longtime consumer advocate and co-founder of the Patient Safety Action Network. “People might be encouraged to get a knee replacement, when in reality something less invasive could have improved their condition.”

McGiffert recounted a conversation with an orthopedic surgeon in Washington state who told her about a patient who requested a knee replacement, even though he had not tried any lower-impact treatments to fix the problem. “I asked the surgeon, ‘You didn’t do it, did you?’ And he said, ‘Of course I did. He would just have gone to somebody else.’”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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What Seniors Can Expect as Their New Normal in a Post-Vaccine World

Imagine this scenario, perhaps a year or two in the future: An effective COVID-19 vaccine is routinely available and the world is moving forward. Life, however, will likely never be the same — particularly for people over 60.

That is the conclusion of geriatric medical doctors, aging experts, futurists and industry specialists. Experts say that in the aftermath of the pandemic, everything will change, from the way older folks receive health care to how they travel and shop. Also overturned: their work life and relationships with one another.

“In the past few months, the entire world has had a near-death experience,” said Ken Dychtwald, CEO of Age Wave, a think tank on aging around the world. “We’ve been forced to stop and think: I could die or someone I love could die. When those events happen, people think about what matters and what they will do differently.”

Older adults are uniquely vulnerable because their immune systems tend to deteriorate with age, making it so much harder for them to battle not just COVID-19 but all infectious diseases. They are also more likely to suffer other health conditions, like heart and respiratory diseases, that make it tougher to fight or recover from illness. So it’s no surprise that even in the future, when a COVID-19 vaccine is widely available — and widely used — most seniors will be taking additional precautions.

“Before COVID-19, baby boomers” — those born after 1945 but before 1965 — “felt reassured that with all the benefits of modern medicine, they could live for years and years,” said Dr. Mehrdad Ayati, who teaches geriatric medicine at Stanford University School of Medicine and advises the U.S. Senate Special Committee on Aging. “What we never calculated was that a pandemic could totally change the dialogue.”

It has. Here’s a preview of post-vaccine life for older Americans:

Medical Care

  • Time to learn telemed. Only 62% of people over 75 use the internet — and fewer than 28% are comfortable with social media, according to data from the Pew Research Center. “That’s lethal in the modern age of health care,” Dychtwald said, so there will be a drumbeat to make them fluent users of online health care.
  • 1 in 3 visits will be telemed. Dr. Ronan Factora, a geriatrician at Cleveland Clinic, said he saw no patients age 60 and up via telemedicine before the pandemic. He predicted that by the time a COVID-19 vaccine is available, at least a third of those visits will be virtual. “It will become a significant part of my practice,” he said. Older patients likely will see their doctors more often than once a year for a checkup and benefit from improved overall health care, he said.
  • Many doctors instead of just one. More regular remote care will be bolstered by a team of doctors, said Greg Poland, professor of medicine and infectious diseases at the Mayo Clinic. The team model “allows me to see more patients more efficiently,” he said. “If everyone has to come to the office and wait for the nurse to bring them in from the waiting room, well, that’s an inherent drag on my productivity.”
  • Drugstores will do more vaccinations. To avoid the germs in doctors’ offices, older patients will prefer to go to drugstores for regular vaccinations such as flu shots, Factora said.
  • Your plumbing will be your doctor. In the not-too-distant future — perhaps just a few years from now — older Americans will have special devices at home to regularly analyze urine and fecal samples, Dychtwald said, letting them avoid the doctor’s office.

Travel

  • Punch up the Google Maps. Many trips of 800 miles or less will likely become road trips instead of flights, said Ed Perkins, a syndicated travel columnist for the Chicago Tribune. Perkins, who is 90, said that’s certainly what he plans to do — even after there’s a vaccine.
  • Regional and local travel will replace foreign travel. Dychtwald, who is 70, said he will be much less inclined to travel abroad. For example, he said, onetime plans with his wife to visit India are now unlikely, even if a good vaccine is available, because they want to avoid large concentrations of people. That said, each year only 25% of people 65 and up travel outside the U.S. annually, vs. 45% of the general population, according to a survey by Visa. The most popular trip for seniors: visiting grandchildren.
  • Demand for business class will grow. When older travelers (who are financially able) choose to fly, they will more frequently book roomy business-class seats because they won’t want to sit too close to other passengers, Factora said.
  • Buying three seats for two. Older couples who fly together — and have the money — will pay for all three seats so no one is between them, Perkins said.
  • Hotels will market medical care. Medical capability will be built into more travel options, Dychtwald said. For example, some hotels will advertise a doctor on-site — or one close by. “The era is over of being removed from health care and feeling comfortable,” he said.
  • Disinfecting will be a sales pitch. Expect a rich combination of health and safety “theater” — particularly on cruises that host many older travelers, Perkins said: “Employees will be wandering around with disinfecting fogs and wiping everything 10 times.”
  • Cruises will require proof of vaccination. Passengers — as well as cruise employees — will likely have to prove they’ve been vaccinated before traveling, Factora said.

Eating/Shopping

  • Local eateries will gain trust. Neighborhood and small-market restaurants will draw loyal customers — mainly because they know and trust the owners, said Christopher Muller, a hospitality professor at Boston University.
  • Safety will be a bragging point. To appeal to older diners in particular, restaurants will prominently display safety-inspection signage and visibly signal their cleanliness standards, Muller said. They will even hire employees exclusively to wipe down tables, chairs and all high-touch points — and these employees will be easy to identify and very visible.

Home Life

  • The homecoming. Because of so many COVID-19 deaths in nursing homes, more seniors will leave assisted living facilities and nursing homes to move in with their families, Factora said. “Families will generally move closer together,” he said.
  • The fortress. Home delivery of almost everything will become the norm for older Americans, and in-person shopping will become much less common, Factora said.
  • Older workers will stay home. The 60-and-up workforce increasingly will be reluctant to work anywhere but from home and will be very slow to re-embrace grocery shopping. “Instacart delivery will become the new normal for them,” Dychtwald said.

Gatherings

  • Forced social distancing. Whenever or wherever large families gather, people exhibiting COVID-like symptoms may not be welcomed under any circumstances, Ayati said.
  • Older folks will disengage, at a cost. Depression will skyrocket among older people who isolate from family get-togethers and large gatherings, Ayati said. “As the older population pulls back from engaging in society, this is a very bad thing.”
  • Public restrooms will be revamped. For germ avoidance, they’ll increasingly get no-touch toilets, urinals, sinks and entrances/exits. “One of the most disastrous places you can go into is a public restroom,” Poland said. “That’s about the riskiest place.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Technology Divide Between Senior ‘Haves’ and ‘Have-Nots’ Roils Pandemic Response

Family gatherings on Zoom and FaceTime. Online orders from grocery stores and pharmacies. Telehealth appointments with physicians.

These have been lifesavers for many older adults staying at home during the coronavirus pandemic. But an unprecedented shift to virtual interactions has a downside: Large numbers of seniors are unable to participate.

Among them are older adults with dementia (14% of those 71 and older), hearing loss (nearly two-thirds of those 70 and older) and impaired vision (13.5% of those 65 and older), who can have a hard time using digital devices and programs designed without their needs in mind. (Think small icons, difficult-to-read typefaces, inadequate captioning among the hurdles.)

Many older adults with limited financial resources also may not be able to afford devices or the associated internet service fees. (Half of seniors living alone and 23% of those in two-person households are unable to afford basic necessities.) Others are not adept at using technology and lack the assistance to learn.

During the pandemic, which has hit older adults especially hard, this divide between technology “haves” and “have-nots” has serious consequences.

Older adults in the “haves” group have more access to virtual social interactions and telehealth services, and more opportunities to secure essential supplies online. Meanwhile, the “have-nots” are at greater risk of social isolation, forgoing medical care and being without food or other necessary items.

Dr. Charlotte Yeh, chief medical officer for AARP Services, observed difficulties associated with technology this year when trying to remotely teach her 92-year-old father how to use an iPhone. She lives in Boston; her father lives in Pittsburgh.

Yeh’s mother had always handled communication for the couple, but she was in a nursing home after being hospitalized for pneumonia. Because of the pandemic, the home had closed to visitors. To talk to her and other family members, Yeh’s father had to resort to technology.

But various impairments got in the way: Yeh’s father is blind in one eye, with severe hearing loss and a cochlear implant, and he had trouble hearing conversations over the iPhone. And it was more difficult than Yeh expected to find an easy-to-use iPhone app that accurately translates speech into captions.

Often, family members would try to arrange Zoom meetings. For these, Yeh’s father used a computer but still had problems because he could not read the very small captions on Zoom. A tech-savvy granddaughter solved that problem by connecting a tablet with a separate transcription program.

When Yeh’s mother, who was 90, came home in early April, physicians treating her for metastatic lung cancer wanted to arrange telehealth visits. But this could not occur via cellphone (the screen was too small) or her computer (too hard to move it around). Physicians could examine lesions around the older woman’s mouth only when a tablet was held at just the right angle, with a phone’s flashlight aimed at it for extra light.

“It was like a three-ring circus,” Yeh said. Her family had the resources needed to solve these problems; many do not, she noted. Yeh’s mother passed away in July; her father is now living alone, making him more dependent on technology than ever.

When SCAN Health Plan, a Medicare Advantage plan with 215,000 members in California, surveyed its most vulnerable members after the pandemic hit, it discovered that about one-third did not have access to the technology needed for a telehealth appointment. The Centers for Medicare & Medicaid Services had expanded the use of telehealth in March.

Other barriers also stood in the way of serving SCAN’s members remotely. Many people needed translation services, which are difficult to arrange for telehealth visits. “We realized language barriers are a big thing,” said Eve Gelb, SCAN’s senior vice president of health care services.

Nearly 40% of the plan’s members have vision issues that interfere with their ability to use digital devices; 28% have a clinically significant hearing impairment.

“We need to target interventions to help these people,” Gelb said. SCAN is considering sending community health workers into the homes of vulnerable members to help them conduct telehealth visits. Also, it may give members easy-to-use devices, with essential functions already set up, to keep at home, Gelb said.

Landmark Health serves a highly vulnerable group of 42,000 people in 14 states, bringing services into patients’ homes. Its average patient is nearly 80 years old, with eight medical conditions. After the first few weeks of the pandemic, Landmark halted in-person visits to homes because personal protective equipment, or PPE, was in short supply.

Instead, Landmark tried to deliver care remotely. It soon discovered that fewer than 25% of patients had appropriate technology and knew how to use it, according to Nick Loporcaro, the chief executive officer. “Telehealth is not the panacea, especially for this population,” he said.

Landmark plans to experiment with what he calls “facilitated telehealth”: nonmedical staff members bringing devices to patients’ homes and managing telehealth visits. (It now has enough PPE to make this possible.) And it, too, is looking at technology that it can give to members.

One alternative gaining attention is GrandPad, a tablet loaded with senior-friendly apps designed for adults 75 and older. In July, the National PACE Association, whose members run programs providing comprehensive services to frail seniors who live at home, announced a partnership with GrandPad to encourage adoption of this technology.

“Everyone is scrambling to move to this new remote care model and looking for options,” said Scott Lien, the company’s co-founder and chief executive officer.

PACE Southeast Michigan purchased 125 GrandPads for highly vulnerable members after closing five centers in March where seniors receive services. The devices have been “remarkably successful” in facilitating video-streamed social and telehealth interactions and allowing nurses and social workers to address emerging needs, said Roger Anderson, senior director of operational support and innovation.

Another alternative is technology from iN2L (an acronym for It’s Never Too Late), a company that specializes in serving people with dementia. In Florida, under a new program sponsored by the state’s Department of Elder Affairs, iN2L tablets loaded with dementia-specific content have been distributed to 300 nursing homes and assisted living centers.

The goal is to help seniors with cognitive impairment connect virtually with friends and family and engage in online activities that ease social isolation, said Sam Fazio, senior director of quality care and psychosocial research at the Alzheimer’s Association, a partner in the effort. But because of budget constraints, only two tablets are being sent to each long-term care community.

Families report it can be difficult to schedule adequate time with loved ones when only a few devices are available. This happened to Maitely Weismann’s 77-year-old mother after she moved into a short-staffed Los Angeles memory care facility in March. After seeing how hard it was to connect, Weismann, who lives in Los Angeles, gave her mother an iPad and hired an aide to ensure that mother and daughter were able to talk each night.

Without the aide’s assistance, Weismann’s mother would end up accidentally pausing the video or turning off the device. “She probably wanted to reach out and touch me, and when she touched the screen it would go blank and she’d panic,” Weismann said.

What’s needed going forward? Laurie Orlov, founder of the blog Aging in Place Technology Watch, said nursing homes, assisted living centers and senior communities need to install communitywide Wi-Fi services — something that many lack.

“We need to enable Zoom get-togethers. We need the ability to put voice technology in individual rooms, so people can access Amazon Alexa or Google products,” she said. “We need more group activities that enable multiple residents to communicate with each other virtually. And we need vendors to bundle connectivity, devices, training and service in packages designed for older adults.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Decreasing Inflammation and Oxidation After Meals

Within hours of eating an unhealthy meal, we can get a spike in inflammation, crippling our artery function, thickening our blood, and causing a fight-or-flight nerve response. Thankfully, there are foods we can eat at every meal to counter this reaction.

Standard American meals rich in processed junk and meat and dairy lead to exaggerated spikes in sugar and fat in the blood, as you can see at 0:13 in my video How to Prevent Blood Sugar and Triglyceride Spikes after Meals. This generates free radicals, and the oxidative stress triggers a biochemical cascade throughout our circulation, damaging proteins in our body, inducing inflammation, crippling our artery function, thickening our blood, and causing a fight-or-flight nerve response. This all happens within just one to four hours after eating a meal. Worried about inflammation within your body? One lousy breakfast could double your C-reactive protein levels before it’s even lunchtime.

Repeat that three times a day, and you can set yourself up for heart disease. You may not even be aware of how bad off you are because your doctor is measuring your blood sugar and fat levels while you’re in a fasting state, typically drawing your blood before you’ve eaten. What happens after a meal may be a stronger predictor of heart attacks and strokes, which makes sense, since this is where most of us live our lives—that is, in a fed state. And it’s not just in diabetics. As you can see at 1:30 in my video, if you follow non diabetic women with heart disease but normal fasting blood sugar, how high their blood sugar spikes after chugging some sugar water appears to determine how fast their arteries continue to clog up, perhaps because the higher the blood sugars spike, the more free radicals are produced.

So, what are some dietary strategies to improve the situation? Thankfully, “improvements in diet exert profound and immediate favorable changes…,” but what kind of improvements? “Specifically, a diet high in minimally processed, high-fiber, plant-based foods such as vegetables and fruits, whole grains, legumes, and nuts,”—antioxidant, anti-inflammatory whole plant foods—“will markedly blunt the post-meal increase” in sugar, fat, and inflammation.

But what if you really wanted to eat some Wonder Bread? As you can see at 2:23 in my video, you’d get a big spike in blood sugar less than an hour after eating it. Would it make a difference if you spread the bread with almond butter? Adding about a third of a cup of almonds to the same amount of Wonder Bread significantly blunts the blood sugar spike.

In that case, would any low-carb food help? Why add almond butter when you can make a bologna sandwich? Well, first of all, plant-based foods have the antioxidants to wipe out any excess free radicals. So, nuts can not only blunt blood sugar spikes, but oxidative damage as well. What’s more, they can even blunt insulin spikes. Indeed, adding nuts to a meal calms both blood sugar levels and insulin levels, as you can see at 3:02 in my video. Now, you’re probably thinking, Well, duh, less sugar means less insulin, but that’s not what happens with low-carb animal foods.

As you can see at 3:23 in my video, if you add steamed skinless chicken breast to your white rice, you get a greater insulin spike than if you had just eaten the white rice alone. So, adding the low-carb plant food made things better, but adding the low-carb animal food made things worse. It’s the same with adding chicken breast to mashed potatoes—a higher insulin spike with the added animal protein. It is also the same with animal fat: Add some butter to a meal, and get a dramatically higher insulin spike from some sugar, as you can see at 3:45 in my video.

If you add butter and cheese to white bread, white potatoes, white spaghetti, or white rice, you can sometimes even double the insulin reaction. If you add half an avocado to a meal, however, instead of worsening, the insulin response improves, as it does with the main whole plant food source of fat: nuts.


I’ve covered the effect adding berries to a meal has on blood sugar responses in If Fructose Is Bad, What About Fruit?, and that raises the question: How Much Fruit Is Too Much?

In addition to the all-fruit jam question, I cover The Effects of Avocados and Red Wine on Postprandial Inflammation.

Vinegar may also help. See Can Vinegar Help with Blood Sugar Control?.

Perhaps this explains part of the longevity benefit to nut consumption, which I discuss in Nuts May Help Prevent Death.

I also talk about that immediate inflammatory reaction to unhealthy food choices in Best Foods to Improve Sexual Function.

Surprised by the chicken and butter reaction? The same thing happens with tuna fish and other meat, as I cover in my video Paleo Diets May Negate Benefits of Exercise.

Also check:

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

 

States Allow In-Person Nursing Home Visits As Families Charge Residents Die ‘Of Broken Hearts’

States across the country are beginning to roll back heart-wrenching policies instituted when the coronavirus pandemic began and allow in-person visits at nursing homes and assisted living centers, offering relief to frustrated families.

For the most part, visitors are required to stay outside and meet relatives in gardens or on patios where they stay at least 6 feet apart, supervised by a staff member. Appointments are scheduled in advance and masks are mandated. Only one or two visitors are permitted at a time.

Before these get-togethers, visitors get temperature checks and answer screening questions to assess their health. Hugs or other physical contact are not allowed. If residents or staff at a facility develop new cases of COVID-19, visitation is not permitted.

As of July 7, 26 states and the District of Columbia had given the go-ahead to nursing home visits under these circumstances, according to LeadingAge, an association of long-term care providers. Two weeks earlier, the Centers for Medicare & Medicaid Services clarified federal guidance on reopening nursing homes to visitors.

Eighteen states and the District of Columbia were similarly planning to allow visits at assisted living centers.

Visitation policies may change, however, if state officials become concerned about a rise in COVID-19 cases. And individual facilities are not obligated to open up to families, even when a state says they can do so.

Relaxing restrictions is not without risks. Frail older adults in long-term care are exceptionally vulnerable to COVID-19. According to various estimates, 40% to 45% of COVID-related deaths have occurred in these facilities.

But anguished families say loved ones are suffering too much, mentally and physically, after nearly four months in isolation. Since nursing homes and assisted living centers closed to visitors in mid-March, under guidance from federal health authorities, older adults have been mostly confined to their rooms, with minimal human interaction.

The goal was to protect residents from the coronavirus as the pandemic began to escalate. But the virus entered facilities nonetheless as staffers came and went. And now, families argue, the harms of isolation exceed potential benefits.

“My mother stopped eating around the middle of April — now she just picks at her food,” said Marlisa Mills of Asheville, North Carolina. “Every week, she becomes more delusional.” Mill’s mother, 95, has dementia and lives in a nearby nursing home that remains closed to visitors.


Residents “are dying of broken hearts and neglect,” said Lelia Sizemore, whose 84-year-old father’s health deteriorated precipitously after her mother stopped her daily visits to his Dayton, Ohio, nursing home in early March.

Diagnosed with severe dementia, blind and unable to feed himself, Sizemore’s father lost more than 10 pounds in two months and succumbed to respiratory failure on May 24. Even at the end, the nursing home refused her mother’s requests to see him in person.

“I didn’t even get to say goodbye,” sobbed Sizemore, who lives in Oregon and last saw her father in July 2019.

Ohio began allowing visitors at assisted living centers on June 8 and will permit outdoor get-togethers at nursing homes as of July 20.

New Jersey has the second-highest number of COVID deaths in the country. On June 19, the state’s health commissioner announced that all long-term care facilities could accept visitors outdoors — just in time for Father’s Day.

Broadway House for Continuing Care, a Newark facility, quickly notified families and arranged to pitch a tent with chairs and tables underneath in a garden area.

“It’s time to open things up some more: We’ve all been operating under a sense of being under house arrest,” said James Gonzalez, chief executive officer of Broadway House and chair of the board of the Health Care Association of New Jersey.

With weekly tests, 10 residents and 26 staffers at Broadway House have learned they had COVID-19. One resident has died since the outbreak began.

“Are we worried about visitors bringing the virus? Yes, but I think we can manage that,” Gonzalez said. “We’re going to have to take this day by day.”

On Father’s Day, Raul Lugo arrived at Broadway House to visit his grandmother, Rosa Perez, 89, who raised him after his mother died when he was an infant. He had not seen Perez, who had contracted COVID-19 and spent two months in the hospital, since the end of March. Because Perez is frail and it was extremely hot, they met in the facility’s vestibule.

“She told me she missed me and that she loves me. I told her I love her back,” said Lugo, a truck driver. “It was 1,000 times better seeing her in person than talking to her on the phone. You can’t compare it. It was awesome.”

Raul Lugo wanted to hug his grandmother, Rosa Perez, 89, during their in-person visit at her nursing home on June 21. The two had not seen each other for three months.(Courtesy of Damary Lugo)

Complete Care Management, which operates 16 nursing homes in New Jersey, opened all its facilities to visitors within a week of the announcement of the state’s new policy.

Complete Care asks visitors to sign consent forms indicating they understand the risks and will let staffers know if they become ill. No one is allowed to bring food or enter the buildings, even to use the restrooms. For the time being, get-togethers are short – no more than 15 minutes and no more than two visitors at a time.

“Really, the only burdensome part of it is having staff available to bring residents outside, wait with them and bring them back in,” said Efraim Siegfried, Complete Care’s chief executive officer. “If we do everything right, I don’t see a negative outcome. And to see how excited people are, how happy they are, it’s a beautiful thing.”

Before the pandemic, Patricia Tietjen, 72, visited her husband of 52 years, Robert, who has dementia, every day at Complete Care at Green Acres in Toms River, New Jersey. Though staffers tried to arrange FaceTime visits when the home closed to visitors, “it was hard because he was never awake – he started sleeping all the time – and he can’t speak anymore,” Tietjen said.

Robert became ill with COVID-19 in April. Although he survived that, he recently entered hospice care and Tietjen has twice been let into the facility because he is near the end of his life. “It was extremely emotional,” she said, breaking into tears.

Although federal guidance says visitors should be permitted inside long-term care facilities at the end of life, this is not happening as often as it should, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy group.

She wants family visitation policies to be mandatory, not optional. As it stands, facility administrators retain considerable discretion over when and whether to offer visits because states are issuing recommendations only.

Smetanka’s organization has also begun a campaign, Visitation Saves Lives, calling for one “essential support person” to be named for every nursing home or assisted living resident, not just those who are dying. This person should have the right to go into the facility as long as he or she wears personal protective equipment, follows infection control protocols and interacts only with his or her loved one.

Not doing so is “inhumane and cruel” punishment for more than 2 million people — most of them older adults — living in “solitary confinement conditions,” said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform, a campaign partner.

High Blood Pressure May Lead to Low Brain Volume

Having hypertension in midlife (ages 40 through 60) is associated with elevated risk of cognitive impairment and Alzheimer’s dementia later in life, even more so than having the so-called Alzheimer’s gene.

“It is clear that cerebral vascular disease”—that is, hardening of the arteries inside our brain—“and cognitive decline travel hand in hand,” something I’ve addressed before. “However, the independent association of AD [Alzheimer’s disease] with multiple AVD [atherosclerotic vascular disease] risk factors suggests that cholesterol is not the sole culprit in dementia.”

As I discuss in my video Higher Blood Pressure May Lead to Brain Shrinkage, one of the most consistent findings is that elevated levels of blood pressure in midlife, ages 40 through 60, is associated with elevated risk of cognitive impairment and Alzheimer’s dementia later in life—in fact, even more so than having the so-called Alzheimer’s gene.

“The normal arterial tree”—all the blood vessels in the brain—“is…designed as both a conduit and cushion.” But when the artery walls become stiffened, the pressure from the pulse every time our heart pumps blood up into our brain can damage small vessels in our brain. This can cause “microbleeds” in our brain, which are frequently found in people with high blood pressure, even if they were never diagnosed with a stroke.

These microbleeds may be “one of the important factors that cause cognitive impairments,” “perhaps not surprising[ly],” because on autopsy, “microbleeds may be associated with [brain] tissue necrosis,” meaning brain tissue death.

And speaking of tissue death, high blood pressure is also associated with so-called lacunar infarcts, from the Latin word lacuna, meaning hole. These holes in our brain appear when little arteries get clogged in the brain and result in the death of a little round region of the brain. Up to a quarter of the elderly have these little mini-strokes, and most don’t even know it, so-called silent infarcts. But “no black holes in the brain are benign.” As you can see at 2:12 in my video, it’s as though your brain has been hole-punched.

“Although silent infarcts, by definition, lack clinically overt stroke-like symptoms, they are associated with subtle deficits in physical and cognitive function that commonly go unnoticed.” What’s more, they can double the risk of dementia. That’s one of the ways high blood pressure is linked to dementia.

There’s so much damage that high blood pressure levels can “lead to brain volume reduction,” literally a shrinkage of our brain, “specifically in the hippocampus,” the memory center of the brain. This helps explain how high blood pressure can be involved in the development of Alzheimer’s disease.

As you can see at 3:02 in my video, we can actually visualize the little arteries in the back of our eyes using an ophthalmoscope, providing “a noninvasive window” to study the health of our intracranial arteries, the little vessels inside our head. Researchers “found a significant association” between visualized arterial disease and brain shrinkage on MRI. However, because that was a cross-sectional study, just a snapshot in time, you can’t prove cause and effect. What’s needed is a prospective study, following people over time. And that’s just what the researchers did. Over a ten-year period, those with visual signs of arterial disease were twice as likely to suffer a significant loss of brain tissue volume over time.


What can we do about high blood pressure? A lot! See, for example:

What else can we do to forestall cognitive decline or dementia? I referenced my video Alzheimer’s and Atherosclerosis of the Brain earlier, and here are other videos that offer information on treatment and prevention:

 

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

A Half Teaspoon of Dried Rosemary May Improve Cognitive Function

In Hamlet, Act 4, Scene 5, Ophelia notes that rosemary is for remembrance, an idea that goes back at least a few thousand years to the ancient Greeks, who claimed that rosemary “comforts the brain…sharpens understanding, restores lost memory, awakens the mind…” After all, “plants can be considered as chemical factories that manufacture all sorts of compounds that could have neuroprotective benefits”. So, let’s cut down on processed foods and eat a lot of phytonutrient-rich whole plant foods, including, perhaps, a variety of herbs. Even the smell of certain herbs may affect how our brain works. Unfortunately, as I discuss in my video Benefits of Rosemary for Brain Function, I’ve found much of the aromatherapy literature scientifically unsatisfying. There are studies offering subjective impressions, for example, but while sniffing an herbal sachet is indeed “easy, inexpensive, and safe,” is it effective? The researchers didn’t even compare test scores.

However, even when there was a control group, such as one study where researchers had people perform a battery of tests in a room that smelled like rosemary, lavender, or nothing, and even when the researchers did compare test results, the lavender appeared to slow down the subjects and impair their performance, whereas the rosemary group seemed to do better. Perhaps that was just because of the mood effects, though, as I show at 1:36 in my video. Maybe the rosemary group did better simply because the aroma pepped them up in some way—and not necessarily in a good way, as perhaps the rosemary was somehow overstimulating in some circumstances?

Now, there have been studies that measured people’s brain waves and were able to correlate the EEG findings with the changes in mood and performance, as well as associate them with objective changes in stress hormone levels, as you can see at 2:05 in my video, but is that all simply because pleasant smells improve people’s moods? For instance, if you created a synthetic rosemary fragrance with a bunch of chemicals that had nothing to do with the rosemary plant, would it have the same effect? We didn’t know…until now.

Aromatic herbs do have volatile compounds that theoretically could enter the blood stream by way of the lining of the nose or lungs and then potentially cross into the brain and have direct effects. A 2012 study was the first to put it to the test. Researchers had people do math in a cubicle infused with rosemary aroma. The subjects got that same boost in performance, but for the first time, the researchers showed that their improvement correlated with the amount of a rosemary compound that made it into their bloodstream just from being in the same room. So, not only did this show that it gets absorbed, but that such natural aromatic plant compounds may have a direct effect on changes in brain function.

If that’s what just smelling it can do, what about eating rosemary? We have studies on alertness, cognition, and reduced stress hormone levels inhaling rosemary. “However, there were no clinical studies on cognitive performance following ingestion of rosemary”…until now. Older adults, average age of 75, were given two cups of tomato juice, with either nothing, a half teaspoon of powdered rosemary, which is what one might use in a typical recipe, a full teaspoon, two teaspoons, more than a tablespoon of rosemary powder, or placebo pills to go even further to eliminate any placebo effects.

“Speed of memory is a potentially useful predictor of cognitive function during aging,” and, as you can see at 4:08 in my video, researchers found that the lowest dose had a beneficial effect, accelerating the subjects’ processing speed, but the highest dose impaired their processing speed, perhaps because the half-teaspoon dose improved alertness, while the four-teaspoon dose decreased alertness. So, “rosemary powder at the dose nearest normal culinary consumption demonstrated positive effects on speed of memory…” The implicit take-home message is more isn’t necessarily better. Don’t take high-dose herbal supplements, extracts, or tinctures—just cooking with spices is sufficient. A conclusion, no doubt, pleasing to the spice company that sponsored the study. No side effects were reported, but that doesn’t mean you can eat the whole rosemary bush. In one study, an unlucky guy swallowed a rosemary twig that punctured through the stomach into his liver, causing an abscess from which two cups of pus and a two-inch twig were removed. So, explore herbs and spices in your cooking. Branch out—just leave the branches out.

That twig is like a plant-based equivalent of Migrating Fish Bones!


Interested in more on aromatherapy? See:

For more on spicing up your life, check out:

And, learn more about improving cognition and preventing age-related cognitive decline in:

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

 

Vitamin D Supplements for Increasing Aging Muscle Strength

We have known for more than 400 years that muscle weakness is a common presenting symptom of vitamin D deficiency. Bones aren’t the only organs that respond to vitamin D—muscles do, too. However, as we age, our muscles lose vitamin D receptors, perhaps helping to explain the loss in muscle strength as we age. Indeed, vitamin D status does appear to predict the decline in physical performance as we get older, with lower vitamin D levels linked to poorer performance. As I discuss in my video in my video Should Vitamin D Supplements Be Taken to Prevent Falls in the Elderly?, maybe the low vitamin D doesn’t lead to weakness. Rather, maybe the weakness leads to low vitamin D. Vitamin D is the sunshine vitamin, so being too weak to run around outside could explain the correlation with lower levels. To see if it’s cause and effect, you have to put it to the test.

As you can see at 1:01 in my video, about a dozen randomized controlled trials have tested vitamin D supplements versus sugar pills. After putting them all together, we can see that older men and women taking vitamin D get significant protection from falls, especially among those who had started out with relatively low levels. This has led the conservative U.S. Preventive Services Task Force, the official prevention guideline setting body, and the American Geriatric Society to “recommend vitamin D supplementation for persons who are at high risk of falls.”

We’re not quite sure of the mechanism, though. Randomized controlled trials have found that vitamin D boosts global muscle strength, particularly in the quads, which are important for fall prevention, though vitamin D supplements have also been shown to improve balance. So, it may also be a neurological effect or even a cognitive effect. We’ve known for about 20 years that older men and women who stop walking when a conversation starts are at particularly high risk of falling. Over a six-month timeframe, few who could walk and talk at the same time would go on to fall, but 80 percent of those who stopped walking when a conversation was initiated ended up falling, as you can see at 2:14 in my video.

Other high-risk groups who should supplement with vitamin D include those who have already fallen once, are unsteady, or are on a variety of heart, brain, and blood pressure drugs that can increase fall risk. There’s also a test called “Get-Up-and-Go,” which anyone can do at home. Time how long it takes you “to get up from an armchair, walk 10 feet, turn around, walk back, and sit down.” If it takes you longer than ten seconds, you may be at high risk.

So, how much vitamin D should you take? As you can see at 3:00 in my video, it seems we should take at least 700 to 1,000 units a day. The American Geriatric Society (AGS) recommends a total of 4,000 IU a day, though, based on the rationale that this should get about 90 percent of people up to the target vitamin D blood level of 75 nanomoles per liter. Although 1,000 IU should be enough for the majority of people, 51 percent, the AGS recommends 4,000 IU to capture 92 percent of the population. That way, you don’t have to routinely test levels, since 4,000 IU will get most people up to the target level and “is considerably below the proposed upper tolerable intake of 10,000 IU/d.” The AGS does not recommend periodic mega-doses.

Despite the AGS’s recommendation, because it’s hard to get patients to comply with pills, why not just give people one megadose, like 500,000 units, once a year, perhaps when they come in for their flu shot? That way, every year, you can at least guarantee an annual spike in vitamin D levels that lasts a few months, as you can see at 4:00 in my video. It’s unnatural but certainly convenient, for the doctor at least. The problem is that it actually increases fall risk, a 30 percent increase in falls in those first three months of the spike. Similar results were found in other mega-dose trials. It may be a matter of too much of a good thing. See, “vitamin D may improve physical performance, reduce chronic pain, and improve mood” so much that people start moving around more and, thereby, increase fall risk. When you give people a whopping dose of vitamin D, they get a burst in physical, mental, and social functioning, and it may take time for their motor control to catch up to their improved muscle function. It would be like giving someone a sports car when they’ve been used to driving a beater. You’ve got to take it slow.

It’s possible, too, that such unnaturally high doses may actually damage the muscles. The evidence the researchers cite in support is a meat industry study showing you can improve the tenderness of steaks by feeding cattle a few million units of vitamin D. The concern is that such high doses may be over-tenderizing our own muscles, as well. Higher vitamin D levels are associated with a progressive drop in fracture risk, but too much vitamin D may be harmful, as you can see at 5:29 in my video.

The bottom line is that vitamin D supplementation appears to help, but the strongest and most consistent evidence for prevention of serious falls is exercise. If you compare the two, taking vitamin D may lower your fall risk compared to placebo, but strength and balance training with or without vitamin D may be even more powerful, as you can see at 5:41 in my video.


Other studies in which vitamin D supplements have been put to the test in randomized placebo-controlled studies, effectively proving—or disproving—their efficacy, are featured in videos such as:

That brings up a number of important questions, which I answer in these videos:

Unfortunately, most supplements are useless—or worse. Here are some additional videos on supplements I’ve produced that may be of interest to you:

For more on the benefits of exercise, see Longer Life Within Walking Distance and How Much Should You Exercise?

In health,
Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations: