You may already know that not getting enough good sleep can cause daytime sleepiness, an inability to make good decisions, car and other accidents, unhealthy food choices, weight gain, depression, high blood pressure, diabetes and a host of other health problems. But could poor sleep increase your risk of Alzheimer’s, too? Three recent studies are pointing us in that direction.
 
In this issue of The ElderCounselor, we will look at the finding of these studies and the latest advancements in the treatment and prevention of Alzheimer’s.
 
Boston University School of Medicine
 
This study, conducted by a team from Boston University School of Medicine, was published in the journal Neurology. They determined that even a small loss of the dreaming phase of sleep, called REM or rapid eye movement sleep, can increase the risk of Alzheimer’s.
 
The Boston team studied 321 people over age 60 who volunteered for a sleep study in the 1990s. Over the next 12 years, 32 developed dementia and of those, 24 were diagnosed with Alzheimer’s. Those who had just a little less REM sleep during the sleep test were more likely to be in the dementia group later. The difference in REM sleep was indeed slight—those who later developed dementia had only 3% less REM sleep than those who did not develop dementia. Most did not even notice the difference in their sleep.
 
It is not clear if the disordered sleep is a cause or an early effect of the dementia process. One of the leaders of the study, Matthew Pace, commented that, “Sleep disturbances are common in dementia but little is known about the various stages of sleep and whether they play a role in dementia risk. Our findings point to REM sleep as a predictor of dementia. The next step will be to determine why lower REM sleep predicts a greater risk of dementia.”
 
Washington University in St. Louis
 
In the second study, published in the journal Brain, a team from Washington University in St. Louis reported that sleep disruption raised levels of amyloid, the protein that clogs the brains of Alzheimer’s patients. They believe that interrupted sleep may allow too much of the compounds, amyloid and tau, to build up and that sleep might help the body clear them away.
 
In this study, the team allowed their group of 17 healthy adults to sleep a normal amount of time but half were prevented from getting deep sleep, called slow-wave sleep. In the mornings, their spinal fluid was analyzed. Those who had their slow-wave sleep disrupted had an increase in their amyloid levels by about 10%. The volunteers also wore sleep monitors to measure their sleep at home. Those who slept poorly for a week at home had measurably higher levels of a second Alzheimer’s associated protein called tau.
 
Amyloid is naturally produced in the brain and researchers know it can cause clogs called plaques. People with more plaques often have memory and thinking problems and dementia but not always, so the amyloid link is not yet entirely clear.
 
Dr. Yo-El S. Ju, who led this study, thinks that interrupted sleep leads to increased brain activity and increased amyloid production. Amyloid is released by brain cells all the time when they fire their synapses, but they don’t release the amyloid when they rest. Dr. Ju thinks the brain may clear out excess levels of amyloid during deep sleep.
 
“When people are in a nice, deep sleep, they get a period of time when, with the normal clearance mechanisms working, the levels of amyloid decrease. If levels are increased over years, they are more likely to cause the clumps, called plaques, which don’t dissolve.”
 
Studies in mice show it takes only an excess of about 10 percent of amyloid to cause amyloid plaques to form. This study showed that just one night of interrupted sleep can increase amyloid levels by 10 percent.
 
Dr. Ju’s team will next study whether treating obstructive sleep apnea, a common cause of sleep disruption, will improve people’s slow-wave sleep and affect amyloid levels.
 
New York University School of Medicine, Rutgers School of Public Health
 
In this study, published in the journal Neurology, researchers at New York University School of Medicine and Rutgers School of Public Health found that sleep apnea can lead to mild cognitive impairment (MCI) nearly 10 years earlier than in those who don’t suffer from breathing problems during sleep. And those with sleep apnea were diagnosed with Alzheimer’s an average of five years earlier than those without sleep issues.
 
Sleep apnea is common in older adults, affecting more than half of all men and a quarter of all women. But many go undiagnosed until they are in a car accident because they are sleepy, they develop high blood pressure or they have a stroke.
 
People with sleep apnea have periods during the night when their throats close up and they briefly stop breathing. Itis caused by a blockage of the airway, usually when the soft tissue in the back of the throat collapses during sleep and briefly closes the throat until the person partially awakens, gasping for air. Other symptoms are loud snoring, choking and snorting while sleeping. Breathing pauses can last from a few seconds to minutes and can happen as many as 300 to 400 times a night, but the person often doesn’t wake up enough to even be aware it is happening. Instead, they wake up in the morning feeling tired.
 
The team reviewed the medical histories of 2,470 people aged 55 to 90 who had participated in an earlier study designed to look for markers of Alzheimer’s disease. They found that sleep apnea was associated with a much quicker decline in cognitive function. But they also found that people who got treatment declined at the same speed as people who didn’t have apnea at all. Treatments can include machines that help people breathe better as they sleep (called CPAP devices), dental appliances (for mild cases) and weight loss.
 
Sleep apnea leads to drops in oxygen levels, which can affect various organs in the body differently and can damage parts of the brain. Dr. Andrew Varga, an Adjunct Instructor in Medicine at New York University and co-author of the study, noted that certain neurons in the hippocampus, where much of Alzheimer’s is thought to start, are very sensitive to drops in oxygen, and sleep apnea may stress out those neurons. Also, as mentioned earlier, the disrupted sleep may prevent the brain from cleaning out the amyloids that can turn into plaques.
 
Recent Developments in Treating Alzheimer’s
 
Currently, more than 5 million Americans have Alzheimer’s. That number is expected to grow to 28 million by 2050 as our population ages. There is no cure. There are a handful of drugs on the market—Aricept, Namenda and Exelon— that were approved more than a decade ago. They can treat symptoms for a while, but they do not affect the disease itself.
 
There are, however, some new drugs in the works that aim to clear amyloid proteins out of the brains of Alzheimer’s patients in hopes of slowing the disease. But they are not even close to being a cure or even being on the market. The three drugs highlighted at the Alzheimer’s Association International Conference are solanezumab, aducanumab and gantenerumab.
 
Solanezumab, made by Eli Lilly, was first released in 2012 and didn’t seem to help patients. But developers continued to follow those in the trials and discovered that those who got the drug early seemed to be doing better, while those who got the drug later could not seem to catch up. Test scores showed very modest changes but could add to more days living at home for those treated very early. Lilly has started a phase III clinical trial, the last stage before seeking FDA approval. Results are more than a year away.
 
Aducanumab, made by Biogen, appears to be clearing the amyloid from the brains of patients and there is some evidence of improving test scores in patients who got the highest doses. Biogen has also started a phase III clinical trial and will test it in people who have very early Alzheimer’s disease or have mild cognitive impairment.
 
Gantenerumab also failed in tests, but it may be that people were not given enough of it. An analysis did show it was affecting tau protein, but higher doses have caused brain inflammation (which could indicate the drugs are working), headaches, dizziness and, in other drug trials, death.
 
Researchers want to offer hope, both for patients and for investors so they will continue to support the development of new drugs. But they caution that real noticeable progress in patients is still years and many dollars away. The Alzheimer’s Association is also asking Congress to fund more government research.
 
Can We Prevent Alzheimer’s?
 
There is no evidence that anything can prevent Alzheimer’s. But there are some things we can do to help slow memory loss and cognitive impairment. These include improving sleep quality, getting regular exercise, controlling blood pressure, engaging in cognitive training and changing eating habits.
 
Improve Sleep Quality:If you, your sleeping partner or a roommate suspect you have sleep apnea, get tested and follow through with any recommended treatment. Other sleep disrupters include restless leg syndrome, insomnia, jet lag, sleepwalking, night terrors, and stress. If your sleep suffers from any of these, talk to your doctor or a sleep specialist about steps you can take to start getting restful sleep.
 
Get regular exercise:Moderate aerobic exercise, like brisk walking, can have an effect on reducing cognitive impairment later in life. Experts say to aim for 150 minutes a week (30 minutes five times a week). Exercise increases the blood flow to all parts of the body, including the brain, improves physical conditioning and lifts your spirits.
 
Lower your blood pressure:Controlling blood pressure helps prevent heart disease. There is also evidence it can reduce the risk of memory loss and dementia because high blood pressure damages delicate blood vessels in the brain.
 
Engage in cognitive training:According to Dr. Ronald Peterson, an Alzheimer’s expert at the Mayo Clinic, this doesn’t mean crossword puzzles or Sudoku, although those won’t hurt. Instead, he suggests working on memory improvement techniques, called mnemonic techniques. These can include finding a new way to remember a list of grocery items; figuring a tip in your head instead of using a calculator; using new strategies that will help you process and locate information more quickly and efficiently; and working on techniques that will help you remember names and other vital information. 
 
Dr. Peterson cautions that most “brain games” have done little more than show they make people better at playing them. He also encourages people to get out and do things, instead of sitting and watching television for hours.
 
Clean up eating habits:You probably know that sugary foods are not good for you. But did you also know that carbs turn into sugar in your body? And did you know that both can have devastating effects on your brain? Dr. David Permutter is a renowned neurologist. His book, Grain Brain, may provide some insights that just might change your life for the better. 
 
Conclusion
 
Alzheimer’s is a devastating disease. There is no cure. Current medicines, when started early, only help with symptoms for a while and have no real effect on the disease itself. Therefore, we owe it to ourselves, our families, and those we serve to do everything we can to protect our brains from Alzheimer’s for as long as possible and to educate others about how to do so. 
 
If we can be of assistance to you or the seniors you work with, please don’t hesitate to reach out.
 
Additional Sources

1. Poor Sleep Raises Alzheimer’s Risk
2. Here’s How Sleep Loss Can Affect Alzheimer’s
3. Sleep Apnea May Speed Memory Loss, Alzheimer’s Onset: Study
4. New Alzheimer’s Drugs Offer “Exciting Possibilities”
5. What Can Prevent Alzheimer’s? Here’s What the Evidence Shows

 

We enjoyed sharing information on Estate Planning and V.A. Benefits to a full house at the Highgate Theatre.  Highgate is a gorgeous facility for independent living, assisted living and memory care.  Contact us or Wendy Hashimoto for more information.

Wendi Hashimoto | Community Relations Coordinator
 
Highgate at Temecula › A senior living community
42301 Moraga Road, Temecula, CA 92591
phone 951-308-1885 cell 909-263-2931
www.HighgateSeniorLiving.com

No one likes to think about the possibility of their own disability or the disability of a loved one. However, as the statistics below demonstrate, we should all plan for at least a temporary disability. This issue of The ElderCounselorTM examines the eye-opening statistics surrounding disability and some of the common disability planning options. Disability planning is one area where we can give each and every person and family we work with great comfort in knowing that, if they or a loved one becomes disabled, they will be prepared.

Most Individuals Will Face At Least a Temporary Disability
Study after study confirms that nearly everyone will face at least a temporary disability sometime during their lifetime. More specifically, one in three Americans will face at least a 90-day disability before reaching age 65 and, according to the definitive study in this area, depending upon their ages, up to 44% of Americans will face a disability of up to 4.7 years. On the whole, Americans are up to 3.5 times more likely to become disabled than die in any given year. 
In raw numbers, over 37 million Americans, or roughly 12% of the total population, are classified as disabled according to the 2010 census. Perhaps surprisingly, more than 50% of those disabled Americans are in their working years, from 18-64. For example, in December 2012, according to the Social Security Administration more than 2.5 million disabled workers in their 20s, 30s, and 40s received SSDI (i.e., disability) benefits.

Many Persons Will Face a Long Term Disability
Unfortunately, for many Americans the disability will not be short-lived. According to the 2007 National Home and Hospice Care Survey, conducted by the Centers for Disease Control's National Center for Health Statistics, over 1.46 million Americans received long term home health care services at any given time in 2007 (the most recent year this information is available). Three-fourths of these patients received skilled care, the highest level of in-home care, and 51% needed help with at least one "activity of daily living" (such as eating, bathing, getting dressed, or the kind of care needed for a severe cognitive impairment like Alzheimer's disease). The average length of service was more than 300 days, and 69% of in-home patients were 65 years of age or older. Patient age is particularly important as more Americans live past age 65. The U.S. Department of Health and Human Services Administration on Aging tells us that Americans over 65 are increasing at an impressive rate.
The Department of Health and Human Services also estimates that 9 million Americans over age 65 will need long term care this year. That number is expected to increase to 12 million by 2020. The Department also estimates that 70% of all persons age 65 or older will need some type of long term care services during their lifetime.
The Council for Disability Awareness provides startling examples of how disability is likely to impact “typical” Americans.
“A typical female, age 35, 5’4", 125 pounds, non-smoker, who works mostly an office job, with some outdoor physical responsibilities, and who leads a healthy lifestyle has the following risks:

• A 24% chance of becoming disabled for 3 months or longer during her working career; with a 38% chance that the disability would last 5 years or longer, and with the average disability for someone like her lasting 82 months.
• If this same person used tobacco and weighed 160 pounds, the risk would increase to a 41% chance of becoming disabled for 3 months or longer.

“A typical male, age 35, 5’10", 170 pounds, non-smoker, who works an office job, with some outdoor physical responsibilities, and who leads a healthy lifestyle has the following risks:

• A 21% chance of becoming disabled for 3 months or longer during his working career; with a 38% chance that the disability would last 5 years or longer, and with the average disability for someone like him lasting 82 months.
• If this same person used tobacco and weighed 210 pounds, the risk would increase to a 45% chance of becoming disabled for 3 months or longer.

Visit the Council for Disability Awareness website at http://www.whatsmypdq.org/ to calculate your own Personal Disability Quotient (PDQ), or risk for disability.

The Alzheimer's Factor
Alzheimer's is growing at an alarming rate. Alzheimer's increased by 46.1% as a cause of death between 2000 and 2006, while causes of death from prostate cancer, breast cancer, heart disease and HIV all declined during that same time period. 

The 2015 Alzheimer's Association annual report titled, “Alzheimer's Disease Facts and Figures” explores different types of dementia, causes and risk factors, and the cost involved in providing health care, among other areas. This report contains some eye-opening statistics:

• An estimated 5.3 million Americans of all ages have Alzheimer's disease. This figure includes 5.1 million people aged 65 and older and 200,000 individuals under age 65 who have younger-onset Alzheimer's. 
• One in nine people age 65 and older (11 percent) has Alzheimer’s disease.
• About one-third of people age 85 and older (32 percent) have Alzheimer’s disease.
• Eighty-one percent of people who have Alzheimer’s disease are age 75 or older. The number of people aged 65 and older with Alzheimer's disease is estimated to reach 7.7 million in 2030 - more than a 50% increase from the 5.1 million aged 65 and older currently affected. 
• Every 67 seconds, someone in the United States develops Alzheimer’s. Thus, approximately 473,000 people age 65 or older developed Alzheimer’s disease in the United States in 2015.
• By 2050, the number of individuals aged 65 and older with Alzheimer's is projected to number between 11 million and 16 million - unless medical breakthroughs identify ways to prevent or more effectively treat the disease. 

​Caregivers are at risk of developing health problems.  There were approximately 10.9 million unpaid caregivers (family members and friends) providing care to persons with Alzheimer's or dementia in 2009. According to the Alzheimer's Association, those persons are at high risk of developing health problems, or worsening existing health issues. For example, family and other unpaid caregivers of people with Alzheimer's or another dementia are more likely than non-caregivers to have high levels of stress hormones, reduced immune function, slow wound healing, new hypertension and new coronary heart disease.

Spouses who are caregivers for the other spouse with Alzheimer's or other dementia are at greater risk for emergency room visits due to their health deteriorating as the result of providing care. A study mentioned in the 2010 Alzheimer's Association report found that caregivers of spouses who were hospitalized for dementia were more likely than caregivers of spouses who were hospitalized for other diseases to die in the following year.

Receiving care.  According to the National Nursing Home Survey 2004 Study, the most recent of its kind, the national average length of stay for nursing home residents is 835 days, with over 56% of nursing home residents staying at least one year. Significantly, only 19% are discharged in less than three months. Those residents who were married or living with a partner at the time of admission had a significantly shorter average stay than those who were widowed, divorced or never married. Likewise, those who lived with a family member prior to admission also had a shorter average stay than those who lived alone prior to admission.

While a relatively small number (1.56 million) and percentage (4.5%) of the 65+ population lived in nursing homes in 2000, the percentage increased dramatically with age, ranging from 1.1% for persons 65-74 years to 4.7% for persons 75-84 years and 18.2% for persons 85+. According to the U.S. Census Bureau, 68% of nursing home residents were women, and only 16% of all residents were under the age of 65. The median age of residents was 83 years.
See Vol. 4 Issue 5 of the Elder Counselor, The Affordable Care Act:  How It Impacts Our Senior Population, for a discussion of the Affordable Care Act’s Impact on information regarding nursing homes.

Long Term Care Costs Can Be Staggering
Not only will many individuals and families face prolonged long term care, in-home care and nursing home costs continue to rise. According to the Genworth 2015 Cost of Care Survey, Assisted Living, Adult Day Services, and Home Care Costs national averages for long term care costs are as follows:

• Monthly base rate (room and board, two meals per day, housekeeping and personal care assistance) for assisted living care is $43,200 annually, expected to increase .2% annually. 
• Daily rate for a private room in a nursing home is $250, or $91,250 annually, expected to increase 4% annually. 
• Daily rate for a semi-private room in a nursing home is $220, or $80,300 annually, expected to increase 4% annually. 
• Hourly rate for home health aides is $21.50, expected to increase 4% annually. 

These costs vary significantly by region, and thus it is critical to know the costs where the individual will receive care. For example, the median annual cost for a private room in the state of California during 2015 was $104,025, whereas the median cost for a year in a semi private room was nearly $90,000.

Most Americans Underestimate the Risk 
Perhaps most importantly, despite overwhelming and compelling statistics; most Americans grossly underestimate the risk of disability to themselves and to their loved ones. According to the Council on Disability Awareness 2010 survey:
 

• 64% of wage earners believe they have a 2% or less chance of being disabled for 3 months or more during their working career; the actual odds for a worker entering the workforce today are closer to 25%.
• Most working Americans estimate that their own chances of experiencing a long term disability are substantially lower than the average worker’s.  

 
Given the high costs of care, this underestimation often leaves Americans ill prepared to pay for the costs of long term care.

Long Term Care Insurance May Cover These Costs
If a parent, their spouse, or family member needs long term care, the cost could easily deplete and/or extinguish the family's hard-earned assets. Alternatively, seniors (or their families) can pay for long term care completely or in part through long term care insurance. 

Most long term care insurance plans let the individual choose the amount of the coverage she wants, as well as how and where she can use her benefits. A comprehensive plan includes benefits for all levels of care, custodial to skilled. Clients can receive care in a variety of settings, including the person's home, assisted living facilities, adult day care centers or hospice facilities. 

Planning in the Event Long Term Care Insurance is Unavailable or Insufficient
Unfortunately, many older Americans will either be medically ineligible for long term care insurance or unable to afford the premiums. In that event, more aggressive planning should be considered as early as possible to make sure life savings are not depleted as a result of having to pay out-of-pocket for care. With the help of an elder law attorney, a plan can be created that will protect much of the assets of an individual or couple that would otherwise be at risk of being depleted. 

All Planning Should Thoroughly Address Disability 
When a person becomes disabled; he or she is often unable to make personal and/or financial decisions. If the disabled person cannot make these decisions, someone must have the legal authority to do so. Otherwise, the family must apply to the court for appointment of a guardian over the person or property, or both. Those who are old enough to remember the public guardianship proceedings for Groucho Marx recognize the need to avoid a guardianship proceeding if at all possible.

At a minimum, seniors need broad powers of attorney that will allow agents to handle all of their property upon disability, as well as the appointment of a decision-maker for health care decisions (the name of the legal document varies by state, but all accomplish the same thing). Alternatively, a fully funded revocable trust can ensure that the senior's person and property will be cared for as desired, pursuant to the highest duty under the law - that of a trustee. 

Conclusion
The above discussion outlines the minimum planning everyone, including seniors and their loved ones, should consider in preparation for a possible disability. It is imperative that families work with a team of professional advisors (legal, medical and financial) to ensure that, in light of their unique goals and objectives, their planning addresses all aspects of a potential disability. Our firm is dedicated to helping seniors and their loved ones work through these issues and implement sound legal planning to address them. If we can help in any way, please don’t hesitate to contact our office.

To comply with the U.S. Treasury regulations, we must inform you that (i) any U.S. federal tax advice contained in this newsletter was not intended or written to be used, and cannot be used, by any person for the purpose of avoiding U.S. federal tax penalties that may be imposed on such person and (ii) each taxpayer should seek advice from their tax advisor based on the taxpayer's particular circumstances.

Most Americans do not know, or refuse to accept, the facts surrounding their potential need for long-term care and the costs associated with it.  This was reconfirmed recently in a telephone survey of 1,735 Americans over the age of 40, funded by the SCAN Foundation and conducted by the Associated Press (AP) – NORC Center for Public Affairs Research (“survey”).[1]  This survey highlights many of the misconceptions Americans have about long-term care, including: the potential that a loved one may need some sort of long-term care within the next five (5) years; lack of knowledge of the positive impact of “person-centered care” practices; lack of understanding of coverage of long-term care services by Medicare, Medicaid and private insurance; and an increase in lack of concern over failure to plan for the costs associated with long-term care.
 
Who Will Need Long-Term Care
 
According to the Genworth Cost of Care Survey of 2015 (“Genworth Survey”)[2], seventy percent (70%) of Americans over the age of sixty-five (65) will eventually need some type of long-term care.  In addition, by the year 2040, twenty-two percent (22%) of the population will be over the age of sixty-five (65), which is a ten percent (10%) increase from the year 2000.  Yet, this survey showed an increasing number of people over the age of forty (40) refusing to believe they will ever need long-term care.
 
Quality of Long-Term Care
 
The survey defined person-centered care as “an approach to health care and supportive services that allows individuals to take control of their own care by specifying preferences and outlining goals that will improve their quality of life.” This approach points to the consideration of coordinated care.  Coordinated care involves communication among various medical providers to reduce overlap, misdiagnosis or other medical oversights. Because many people are avoiding thinking about their golden years, they are missing out on the benefits provided by this approach and the survey shows a lack of appreciation for the improved quality of life it can provide.
 
According to the survey, over sixty-five percent (65%) of adults over the age of forty (40) have two or more doctors that they see on a regular basis.  Twenty-nine percent (29%) of those report that their providers do not communicate well or at all.  Further, the lack of understanding of the person-centered care approach is evident in that twenty-three percent (23%) of those individuals who don’t participate in it reported that it would not improve their quality of care.
 
Cost of Long-Term Care
 
The study showed a lack of understanding by many of coverage for long-term care by Medicare, Medicaid and private health insurance.  The truth is that Medicare does not pay for ongoing long-term care (although it will pay for intermittent stays at nursing facilities).  Yet, thirty-four percent (34%) surveyed thought Medicare would pay for long-term care while twenty-seven percent (27%) were unsure.  Furthermore, Medicare doesn’t typically pay for care in the home.  However, thirty-six percent (36%) of those surveyed thought it would and twenty-seven percent (27%) reported that they were unsure.
 
As for private insurance, most health insurance plans will not cover long-term services like a nursing home or ongoing care provided at home by a licensed home health care aide. Yet, eighteen percent (18%) of Americans age 40 and older believe that their insurance will cover the costs of ongoing nursing home care.  While, twenty-five percent (25%) believe their plan will pay for ongoing care at home. About 1 in 5 people surveyed were unsure of the coverage provided for these types of long-term care services.
 
Medicaid is the largest payer of long-term care services.[3]  Medicaid is a federally and state funded needs-based benefit that will provide for various types of long-term care depending on the state’s regulations.  In 2013, Medicaid paid for fifty-one percent (51%) of the national long-term care bill totaling $310 billion.  However, fifty-one percent (51%) of Americans age 40 and older reported that they don’t expect to have to rely on Medicaid to help pay for their ongoing living assistance expenses as they age.
 
The actual costs for long-term care are staggering.  The Genworth Survey reported that, nationwide, the average bill for a nursing home is approximately $80,300 and for home health care, approximately $44,616 with a variety of options among and in between these levels of care.
 
Planning for Long-Term Care
 
Despite the availability of this information, most Americans are unprepared for the costs associated with long-term care.  For example, the results of the survey showed that only one-third of adults were “very or extremely confident” in their ability to pay for long-term care. Fascinatingly, while many individuals reported being concerned over leaving family with debt or becoming a burden on loved ones, many do little to alleviate their concern in the way of planning. In fact, just over thirty percent (30%) of those over the age of sixty-five (65) reported being concerned with this.  And, finally, two-thirds of Americans over the age of forty (40) reported doing no planning for long-term care.
 
The survey results lead to the conclusion that many Americans are reluctant to face the possible loss of independence related to aging.  Apparently, this plays a role in the unwillingness to plan for the possibility of needing assistance later in life. As an example, there was an interesting difference in the number of people surveyed who had planned, or talked to loved ones about, their funeral arrangements (nearly sixty-five percent (65%)), in those who had discussed care preferences with family (about forty-two percent (42%)) and in those who had saved money for long-term care (approximately thirty-three percent (33%)).  Some things, including how we want to be memorialized are just easier to think about than how we may end up dependent on others.
 
Conclusion
 
Although not a popular topic among Americans over the age of forty, long-term care is an increasingly important one.  We are in the business of providing options for people in planning for their potential long-term care needs.  If you, a loved one or a client needs help figuring out their options, please think of us. We can help and we are always happy to hear from you.

By Jonathan Bick

​Cryptocurrency, such as Bitcoin, has value and therefore is increasingly likely to become an estate asset. Due to the nature of cryptocurrency, typical wills and revocable living trusts may not be well suited to efficiently transfer this new type of asset. Consequently, new estate planning questions and clauses are needed.

While cryptocurrency is not sufficiently mature to allow existing legal structures to promulgate a complete set of rules and regulations, its technological character allows estate planning to protect the intent of clients holding it. However, the lack of statutory structure necessitates proactive steps.

Crypto SecurityCryptocurrency estate planning presents a novel security issue. Cryptocurrency is transferred as a result of following a set of technological protocol rather than presenting legal documents. Secrecy is the primary protection for cryptocurrency, since the identity of the cryptocurrency holder is not required. Thus, probate, a public process which makes all assets in a will and related will documents part of the public record, may compromise the secrecy associated with such secrecy. Probate information may also result in other difficulties related to making the cryptocurrency holder’s heirs a target for hackers or other bad actors.
Cryptocurrency holders may be sufficiently savvy to manage the ever-changing value of their virtual assets, but are unlikely to have that savvy reflected in their estate documents without assistance from their estate professionals. By the same token, due to the enigmatic nature of cryptocurrency, as well as its virtual embodiment, estate professionals may lack sufficient technical know-how to prepare proper estate documents without assistance from their cryptocurrency savvy clients.

Consequently, without timely interaction between cryptocurrency holder and estate professional, said holder risks losing everything for their heirs due to a number of circumstances. Hence, the estate professional must make specific inquiries as to cryptocurrency holdings and prepare cryptocurrency-specific clauses.

Crypto PropertyThe specific inquiries as to cryptocurrency holdings must address the fact that cryptocurrency is treated as property rather than currency for tax purposes. Just like traditional financial assets, the Internal Revenue Service has found that crypto-currency is subject to tax.

Specifically, Notice 2014-21 describes how existing general tax principles apply to transactions using virtual currency. Therefore, capital gain and loss on property transactions involving cryptocurrency must be reported. Such treatment, while well known, is not normally reflected in estate documents.

Next, said inquires and clauses must address the fact that there is no central cryptocurrency authority and, hence, no entity to authorize access to another’s cryptocurrency. Due to this lack of authority to give access to cryptocurrency to an executor or agent under a power of attorney, estate documents must be supplemented by business or technological options to preserve a cryptocurrency holder’s estate.

One supplemental action might be a business service that allows a third party to transfer cryptocurrency to an entity other than the cryptocurrency holder upon the demise of the cryptocurrency holder. Such a transfer service could avoid an unwanted legal duty for an executor or trustee to diversify out of cryptocurrency, and it will relieve them of the need to be cryptocurrency savvy, along with the attending liabilities.

A technological solution, which results in the sale of cryptocurrency due to predetermined conditions, such as the cryptocurrency holder’s failure to renew a cryptocurrency covered option, will have the same results. Like the business option, it will eliminate or ameliorate the need for cryptocurrency clauses in the related estate documents.

Another technological option is to use an Internet application that will transfer cryptocurrency to a revocable living trust upon the execution of a will. Once this application is fully executed, the cryptocurrency will then be subject to a trust and the responsibility of the trustee named in the application.

However, simply using an Internet application to transfer cryptocurrency is insufficient to protect the cryptocurrency; the holder will still need to leave instructions with an executor, with a recitation as to how to transfer these assets into a trust. Ideally, the transfer keys should remain in the control of, and transferred to, the heirs of the cryptocurrency holder in a letter that is stored with the estate documents.

If neither business nor technological estate document supplements are employed, then estate professionals must actively encourage cryptocurrency holders to document that they own cryptocurrency, document where they bought the cryptocurrency, and how a third party can get access to it.

Such information is required because unlike traditional assets, cryptocurrency holders can buy cryptocurrency without communicating their identity. It should be noted that not all cryptocurrency transactions are anonymous. For example, cryptocurrency associated with South Korea is regulated, and such regulations require cryptocurrency holders to be identified.

At a minimum, estate professionals should encourage cryptocurrency holders to keep a dynamic written record of what cryptocurrency they own, where it is located, what they paid for it, from whom they acquired it, and, if they sold their cryptocurrency, the amount for which it was sold. Most importantly, estate professionals should encourage cryptocurrency holders to record the private digital key needed to access it.

Normally, crypto-currency exchanges do not ask for the identity of the cryptocurrency holder, much less request that a cryptocurrency holder record the name of a beneficiary. As a result, failure to secure sufficient information concerning cryptocurrency for a particular holder may result in the need for unnecessary asset accounting, and possibly expensive and time-consuming litigation.

In addition to updating wills and revocable living trusts, power of attorney authorization should be updated to reflect the need for a specific person to act on behalf of cryptocurrency holders. The wills and revocable living trusts should include information related to how to distribute cryptocurrency. The power of attorney authorization should allow entities acting on behalf of the cryptocurrency holder to access the holder’s computers, storage devices, accounts and data, so as to facilitate the transfer or disposition of the cryptocurrency.
​
Ideally, such updating of wills, revocable living trusts and power of attorney authorization should be accompanied by administrative and technological actions by the cryptocurrency holder. Estate professionals should advise their cryptocurrency holder clients to place cryptocurrency information (such as the information noted above) on a USB drive, or paper, and place it in a bank safe deposit box or home safe. Such precautions will make losing cryptocurrency less likely.
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Jonathan Bick is of counsel at Brach Eichler in Roseland, NJ. He is also an adjunct professor at Pace and Rutgers law schools, and the author of 101 Things You Need to Know About Internet Law (Random House 2000). He can be reached at bickj@bicklaw.com.

​On April 2, the Centers for Medicare & Medicaid Services (CMS) expanded how it defines the “primarily health-related” benefits that insurers are allowed to include in their Medicare Advantage policies. As a result, when these plans roll out their coverage for 2019, new benefits may include air conditioners for people with asthma, healthy groceries, rides to medical appointments, home-delivered meals, and non-skilled home-care services.
 
In this issue of The ElderCounselor, we will look at how Medicare Advantage Plans work, the benefits they provide, what the expansion means, and how it may impact both seniors and the plan providers.
 
Background
Medicare is government-sponsored health care for those age 65 years and older. Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. Part B covers doctors’ services, outpatient care, medical supplies, and preventative services.
 
However, there are deductibles and copayments for Medicare that can add up quickly. Also, there is no limit on annual out-of-pocket expenses. Most people buy a supplemental insurance policy, called Medigap insurance. It “fills in the gaps” of Medicare and pays deductibles and copayments. These policies are sold through private insurance companies approved by Medicare. Prescription drug coverage is also sold separately as Part D through private insurance companies.
 
Many seniors like the flexibility this combination provides because they can go to any health care provider or facility that accepts Medicare. Medicare pays its share of the approved amount for covered health care costs first, and then Medigap pays its share. However, Medicare can and does deny coverage for a procedure or treatment that it rules is medically unnecessary, and Medigap will only pay its share if Medicare pays first. 
 
Also, there are some expenses that Medicare does not cover that are important to seniors, including hearing aids, vision care and dental care.
 
What Are Medicare Advantage Plans and How Do They Work?
Medicare Advantage Plans, sometimes called Part C, are sold by private insurance companies as an alternative to Original Medicare. If you join a Medicare Advantage Plan, you still have Medicare, but you receive Part A (hospital insurance) and Part B (medical insurance) coverage from the Medicare Advantage Plan, not from Original Medicare. However, Original Medicare will still cover the costs for hospice care, some new Medicare benefits, and some costs for clinical research studies.
 
Medicare pays a fixed amount for care each month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare and they must cover all of the services that Original Medicare covers. However, if one chooses a Medicare Advantage Plan, they cannot use a Medigap policy. In fact, it is against the law for someone to sell a senior on a Medicare Advantage Plan a Medigap policy unless that person is switching back to Original Medicare. (Changing plans is allowed once each year, during open enrollment in the fall.)
 
Medicare Advantage Plans work like HMOs and PPOs. Generally, a Medicare recipient must use facilities, physicians, and pharmacies that participate in the plan’s network. Some allow for non-network coverage. Emergency and urgently needed care are covered both in- and out-of-network.
 
One of the draws for seniors is that Medicare Advantage Plans offer benefits that Medicare does not, including vision, hearing, dental, gym memberships, and health/wellness programs. There are also cost savings. The monthly premium usually includes Medicare prescription drug coverage (Part D). And, while there may be a copayment for covered services, there is an annual limit on out-of-pocket costs. So, once a senior reaches a certain limit, they will pay nothing for covered services for the rest of the year.
 
Some Shortcomings of Medicare Advantage Plans
There is a multitude of Medicare Advantage Plans, even within one service area. This can be confusing to consumers who must re-evaluate them each year. Each plan can charge different out-of-pocket costs. They can also have different rules for how services are received, such as whether a referral is needed to see a specialist. And they usually have different networks of facilities and providers.
 
Each year, plans set the amounts they charge for premiums, copays, deductibles, and services. The plan (rather than Medicare) decides how much someone pays for the covered services, and it is allowed to change how much the insured would pay only once a year, on January 1. (This is the effective date of coverage for each fall’s open enrollment.) However, they can change their network providers and facilities at any time during the year.
 
When considering a Medicare Advantage Plan, consumers must be diligent about understanding which facilities and physicians are included in its network, where they are located, and how to use the plan for routine and emergency care.
 
A plan can also choose not to cover the costs of services that are not medically necessary under Medicare, so it is advisable for a patient to check before they have the service or procedure done. If someone needs a service that the plan says is not medically necessary, they may have to pay all the costs of the service. But that patient would have a right to appeal the decision. They can also ask for a written advance coverage decision to make sure a service is medically necessary and will be covered.
 
Still, of the 61 million people enrolled in Medicare last year, 20 million have opted for a Medicare Advantage Plan. One reason may be that, in recent years, many families have become accustomed to HMOs and PPOs for their health insurance as lower-cost alternatives to traditional health care.
 
What the CMS Ruling Means
According to the CMS, the new rules will expand benefits to items and services that may not be directly considered medical treatment but will provide care and devices that prevent or treat illness or injuries, compensate for physical impairments, address the psychological effects of illness or injuries, or reduce emergency medical care. The goal is to keep people healthy and well, making it easier for them to live longer and more independently. A physician’s order or prescription will not be required, but the new benefits must be “medically appropriate” and recommended by a licensed health care provider.
 
Details of the Medicare Advantage Plan benefit packages for 2019 must first be approved by CMS and will be released in the fall when the annual open enrollment begins. But plan providers already have ideas of what they could include.
 
In addition to transportation to doctors’ offices or better food options, some health insurance experts said additional benefits could include simple modifications in beneficiaries’ homes, such as installing grab bars in the bathroom, or aides to help with daily activities, including dressing, eating, and other personal care needs. The goal is to focus on avoiding injuries or exacerbating existing health conditions.
Non-skilled in-home care services will also be allowed for the first time as a supplemental benefit, providing they compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room use.
 
Home health care providers have already partnered with Medicare Advantage Plans, and many believe the plans will be willing to pay for non-skilled in-home care with an eye on saving money over the long-term. Medicare Advantage Plans have greater flexibility than the fee-for-service providers have, and in many cases do not have a homebound requirement. Because they receive a set amount per patient from Medicare, they would be more inclined to provide any services, including private duty nursing, to ensure the patient doesn’t cost them more money than necessary.
 
What to Watch
Seniors on Medicare have said that when considering Medicare Advantage Plans, access to certain hospitals and doctors is a top priority for them. Original Medicare includes the vast majority of providers and the broadest possible provider network.
 
But Medicare Advantage Plans are gaining in popularity. According to CMS, in 2015, 35% of Medicare beneficiaries were participants in Medicare Advantage Plans. That number is expected to grow quickly over the next several years. New, attractive benefits coming in 2019 (especially non-skilled in-home care) will likely persuade even more seniors to join Medicare Advantage Plans.
 
That’s certainly good news for the Medicare Advantage Plan industry. And it will be good for seniors if it lets them stay in their homes longer and lead healthier, more independent lives.