Can Aging be Stopped and/or Reversed?

An intriguing article, "Purging the body of 'retired' cells could reverse ageing," published in the Guardian, reconsiders the question: "Can aging be stopped and or reversed?  The articles suggest that recent scientific advances suggest that purging retired cells from the body can reverse the ravages of old age.  New research raises the prospects of new life-extending treatments, and preventative therapies resulting from sweeping away dormant cells, :senescent cells" that  fail to divide genetically due to age, but create mischievous and malicious health impacts as they persis and build-up in an aging body.

The article reads as follows: 

When mice were treated with a substance designed to sweep away cells that have entered a dormant state due to DNA damage their fur regrew, kidney function improved and they were able to run twice as far as untreated elderly animals.

The team are now assessing whether the mice also live longer and are planning a series of safety studies in humans with the ultimate goal of testing whether getting rid of so-called senescent cells could help reverse a range of age-related disorders.

The discovery adds to a wave of new findings hinting at the possibility of a future in which doctors can treat ageing itself, rather than trying to combat the host of diseases that come along with it.

Such a scenario is now supported by science, according to Peter de Keizer, the 36-year-old scientist who led the latest work at Erasmus University Medical Center in the Netherlands. “Maybe when you get to 65 you’ll go every five years for your anti-senescence shot in the clinic. You’ll go for your rejuvenation shot,” he said. “That I can envision when we reach that age.”

Go here to read the rest of the article.  

Man Transported to SNF But Dropped Off at Wrong Location Found Alive Three Days Later

Among the inherent risks of institutional care is transport error.  An object lesson comes in the recent story of an Illinois man  who was dropped off at an intersection nearly ten 10 miles from the nursing home where he was supposed to be admitted.  He was found nearby in a ditch in a three days after.

Michael Bennett, 66, was in the process of being transferred from the Chicago Behavioral Hospital in Des Plaines, IL, to Westwood Nursing Home in Chicago. He was left at an intersection in Des Plaines approximately 10 miles away from the nursing home, according to authorities.  Illinois State Police issued a missing and endangered alert for Bennett. After seeing the alert, a citizen spotted Bennett curled up in a ditch three days later. Bennett was taken to a local hospital for evaluation.

The behavioral hospital is responsible for transporting discharged patients,  An administrator at Westwood told local reporters he was “mystified” that the driver didn't attempt to escort Bennett inside the nursing home, or notice that the facility was not located at the intersection.

The hospital had no comment on the incident.

To read other articles regarding the risks of transport, go here and here.

Aging in Place: Home Health Care Gets Best Outcomes for Knee and Hip Replacement Recovery

Aging in Place continues to be supported by scientific research and surveys.  The most recent research demonstrates that patients who go straight home from the hospital following hip or knee replacement surgery recover as well as, or better than, those who first go to a skilled nursing facility or rehabilitation center. Importantly, the research demonstrates that these health outcomes include those who live alone without family or friends.  

The research was reported in HealthDay, in an article appropriately entitled, "Home Beats Rehab for Knee, Hip Replacement Recovery."  According to the article, 

"We can say with confidence that recovering independently at home does not put patients at increased risk for complications or hardship, and the vast majority of patients were satisfied," said that study's co-author, Dr. William Hozack. He is an orthopaedic surgery professor with the Rothman Institute at the Thomas Jefferson University Medical School in Philadelphia.

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"Considerable evidence has now shown that most patients do just as well at home," he noted.

Hozack and his colleagues are presenting their findings in San Diego at a meeting of the American Academy of Orthopaedic Surgeons (AAOS).  Two other studies being presented at the meeting also found that recovering at home may be the better option.

One study found that patients who are discharged directly home following a total knee replacement face a lower risk for complications and hospital readmission than those who first go to an inpatient rehab facility. The study was led by Dr. Alexander McLawhorn, an orthopaedic hip and knee surgeon at the Hospital for Special Surgery in New York City.

McLawhorn was also part of a second Hospital for Special Surgery study, led by Michael Fu. That study found that hip replacement patients admitted to an inpatient facility rather than being sent home faced a higher risk for respiratory, wound and urinary complications, and a higher risk for hospital readmission and death.

Dr. Claudette Lajam is chief orthopaedic safety officer with NYU Langone Orthopaedics in New York City. She was not involved with the studies, but agrees that home recovery is the best option for most patients.  "The home setting is the single best way to get people back into their routines as quickly as possible after surgery," she told HealthDay.

"In some cases, this cannot be done," Lajam acknowledged. "Some patients live in settings that are inaccessible, [such as] a 5th-floor walk-up apartment where the patient would need to go downstairs to let the visiting nurse and therapist in the door." For some patients, anxiety about the recovery process could also pose a challenge, she added.

But "being in an institutional setting after surgery only reinforces the idea that the patient is 'sick,' " Lajam added. "We have learned that this type of thinking slows down recovery. We want our total joint patients to start using their new joints as quickly as possible, and staying in bed at a nursing facility is not the way to do this."

Because home environments vary, Hozack and his colleagues set out to see whether patients who live alone fare as well as those who live with others.  All 769 patients enrolled in the study by Hozack's team went home following either a total hip replacement or a total knee replacement. Of those, 138 lived alone (about 18 percent).

Once home, all were assessed on multiple levels, including functionality (ability to move); pain levels; hospital readmissions; emergency department visits; unscheduled doctor visits; dependency on assisted-walking devices; and time before returning to work or being able to drive again.  Hozack's team observed no differences by any measure. And while those who lived with others indicated relatively higher satisfaction levels at the two-week mark, by the three-month point there was no appreciable difference between the two groups.

"We feel that giving patients back their independence early on is the best way to promote a safe and effective recovery," said Hozack. His team concluded that single-household patients who go straight home can expect to fare as well as those who have live-in support.

According to HealthDay, a recent Mayo Clinic study calculated that between 2000 and 2010, the number of Americans who underwent hip replacement surgery more than doubled, rising from just under 140,000 to more than 310,000 per year.  Meanwhile, AAOS figures indicate that in 2010 more than 650,000 knee replacement procedures were performed, with about 90 percent involving total knee replacement.  AAOS estimates from 2014 show that 4.7 million Americans now live with an artificial knee and 2.5 million have an artificial hip.

Findings presented at the upcoming meetings are considered preliminary until published in a peer-reviewed journal.

Lawsuit Claims New York's Largest For-profit SNF Operator Kept Nurses in 'Indentured Servitude'

As the consequences of institutional health care for the elderly come to light, so do the consequences to those who work in the institutional elderly care industry. This blog has not before focused on the plight of workers in the industry, but will do so on a going forward basis.  The reason?  One can't expect quality health care from an industry that does not seek, keep, and maintain the highest quality personnel. There is, unfortunately, mounting anecdotal evidence that some in the industry often compromise in staffing decisions in ways one might expect would adversely affect health care outcomes.  

A newly filed class action lawsuit claims that New York's largest for-profit nursing home group allegedly kept more than 350 Filipino nurses in “indentured servitude” and sued those who tried to quit.  The lawsuit was reported in an article published in McKnight's.

The complaint was filed against SentosaCare by former employee and registered nurse Rose Ann Paguirigan. She said she was recruited from the Philippines to work for SentosaCare and eventually signed a contract to work for a Staten Island facility operated by the provider.

The contract stated that Paguirigan would be employed full time as a registered nurse and paid a base salary; instead, she was employed as an RN manager, given 35 hours of work each week and paid less than the wage stated in the contract.

Similar contracts were signed by hundreds of other foreign nurses recruited by the company, although SentosaCare and its recruiter, Prompt Nursing Recruitment Agency, have “policies and practices” to not give foreign nurses full time work or pay them the prevailing wage, Paguirigan's complaint states.

The filing also claims that the provider maintains a “deliberate scheme, pattern and plan” meant to convince foreign nurses that they would “suffer serious harm” if they quit the company or tried to find work elsewhere. This scheme included a reported $25,000 penalty placed in the nurses' contracts that they must pay if they left SentosaCare before the end of their contract term.

Paguirigan argues that a local court found the $25,000 “Indentured Servitude Penalty” unenforceable in 2010, but that SentosaCare, Prompt Nursing and its owners continue to use the penalty in its foreign nursing contracts.

The provider has filed lawsuits against at least 30 nurses since 2006 to collect the penalty, and has sought criminal indictments against at least 10 nurses and a lawyer retained to advise them, according to the complaint.

“The purpose of these lawsuits against plaintiff and other foreign nurses was not to recover actual losses, but to send a message to all foreign nurses that they will face civil litigation and incur substantial attorneys' fees if they stop working for the defendants,” the complaint reads.

The suit seeks compensatory and punitive damages or Paguirigan and other foreign nurses, as well as an injunction barring SentosaCare from threatening to enforce Indentured Servitude Penalties in their contracts, and a declaration that Indentured Servitude Penalties are unenforceable.

SentosaCare has previously been criticized in a ProPublica report for its rapid growth amidst fines and violations.

Developing an "Aging in Place" Guidebook for Your Final Years

Although it is difficult for seniors to plan for their final years, it is foreseeable that a senior may confront some health care issues. According to an article in Kaiser Health News, "A Playbook For Managing Problems In The Last Chapter Of Your Life," there is an interesting website," which helps older adults plan for predictable problems.  The website offers a "guidebook" for the final years.  

 “Many people plan for retirement,” the energetic physician explained in her office close to Lake Michigan. “They complete a will, assign powers of attorney, pick out a funeral home, and they think they’re done.”...What doesn’t get addressed is how older adults will continue living at home if health-related concerns compromise their independence." The focus isn't on end of life planning, according to the article, it's the time before. "Investigators wanted to know which events might make it difficult for people to remain at home. Seniors named five: being hospitalized, falling, developing dementia, having a spouse fall ill or die, and not being able to keep up their homes."

The result of the work is an interactive website that deals with issues such as falls, hospitalization, dementia, finances, and conversations. The website offers that "Plan Your Lifespan will help you learn valuable information and provide you with an easy-to-use tool that you can fill in with your plans, make updates as needed, and easily share it with family and friends." 

Account Transcripts Can Function As Estate Tax Closing Letters

On Jan. 6, the IRS announced that executors, probate courts, state tax departments, and others who rely on estate tax closing letters for confirmation that the IRS has closed its examination of an estate tax return can rely on an account transcript issued by the IRS in place of an estate tax closing letter (Notice 2017-12).

An estate tax closing letter confirms that the IRS has accepted the estate tax return, either as filed or after an IRS adjustment that the estate has agreed to, and the receipt of the letter generally indicates that the estate tax return examination has been closed.

The IRS had issued a closing letter for every estate tax return filed, except for those returns filed only for the purpose of electing portability under Sec. 2010(c)(5)(A) when the portability election was denied. However, since June 1, 2015, the IRS has issued estate tax closing letters only when the estate requests one, and that request must be made at least four months after the estate tax return is filed. Estates and authorized representatives can request an estate tax closing letter by calling the IRS at 866-699-4083.

Because it no longer automatically issues an estate tax closing letter, the IRS has announced that an account transcript can substitute for a closing letter (and is available at no charge). Data in an account transcript include the return-received date, payment history, refund history, penalties and interest assessed, balance due, and the date the examination was closed. According to the IRS if an account transcript includes a transaction code 421 and the explanation "Closed examination of tax return," this means that the Service has closed its examination of the return, and this account transcript can serve as the functional equivalent of an estate tax closing letter.

Estates and their authorized representatives can request an account transcript by filing Form 4506-T, Request for Transcript of Tax Return. The IRS's online Transcript Delivery Service is not available for this purpose; Forms 4506-T must be mailed or faxed to the IRS. The AICPA Trust, Estate & Gift Tax Technical Resource Panel continues to discuss the issue of the unavailability of online estate tax return account transcripts with the IRS.

The IRS's notice comes almost one year after Troy Lewis, CPA, then the chair of the AICPA Tax Executive Committee, sent a letter on behalf of the AICPA to the IRS requesting that the Service formally announce its policy regarding estate tax closing letters and that the IRS consider providing closing letters (and not just account transcripts) through its Transcript Delivery Service (the letter is available at www.aicpa.org). The AICPA also requested the IRS revise Form 706, U.S. Estate (and Generation-Skipping Transfer) Tax Return, to add a box to check to request a closing letter, or allow estates to request a closing letter by adding a handwritten request on top of the first page of the Form 706 or attaching a closing letter request to the Form 706 when it is filed.

- See more here. 

Nursing Homes Cannot Hold Residents' Family Members Who Signed Admission Agreements Personally Responsible for Cost

Courts continue to protect family members of nursing home residents from efforts by institutions to hold family members personally responsible for residents' expense.  These actions are becoming more prevalent as States tighten Medicaid restrictions, leaving more residents with outstanding obligations to the nursing home.  

An Ohio appellate court recently reversed the decision of a trial holding that a son is not personally liable for breach of contract after his father was discharged from a nursing home for non-payment even though the son breached his duty to his father as agent under a power of attorney. Extendicare Health Services v. Dunkerton (Ohio Ct. App., 11th Dist., No. 2015-P-0004, Feb. 6, 2017).

Herbert Dunkerton entered a nursing home after he broke his leg. His son, Michael, signed the admission agreement as his agent under a power of attorney. After Herbert's Medicare coverage was terminated, the nursing home asked that Michael apply for Medicaid on his father's behalf. Michael never applied for Medicaid, and the nursing home eventually discharged Herbert for nonpayment.

The nursing home sued Michael for breach of contract and fraudulent conveyance of Herbert's funds. The trial court ruled that Michael breached his duty as his father’s attorney-in-fact when he refused to apply for Medicaid for his father and entered judgment in the amount of $25,228.43. Michael appealed, arguing that he was not a guarantor of his father's debt.

The Ohio Court of Appeals, Eleventh District, reversed, holding that even though Michael breached his duty as attorney-in-fact, Michael did not breach the admissions agreements with the nursing home. According to the court, Michael "signed the admission agreement and the payor confirmation as his father’s attorney-in-fact, and neither document provides that appellant was Herbert’s voluntary guarantor," so Michael was not responsible for his father's debt pursuant to these agreements. The court notes that under state law an attorney-in-fact can be personally liable under certain circumstances, but the nursing home did not raise the state law in its complaint.


For the full text of this decision, go here.

A North Carolina appellate court recently dismissed a breach of contract lawsuit against a nursing home resident's daughter even though the daughter signed the admission agreement on the grounds that the resident was named as representative in the agreement. Wrightsville Health Holdings, LLC v. Buckner (N.C. Ct. App., No. COA16-726, Feb. 21, 2017).

When Sharon Buckner entered a nursing home, her daughter, Melissa, signed the admission agreement on her behalf. The agreement stated that Sharon was the "resident" and the "representative," but Melissa signed the agreement and initialed the portion stating that the representative agreed to personally guarantee payment in the event the resident's Medicaid application was denied. The nursing home demanded that Melissa pay Sharon's unpaid bill.

After Melissa refused to pay, the nursing home sued her for breach of contract. Melissa filed a motion to dismiss, and the trial court granted the motion. The nursing home appealed.

The North Carolina Court of Appeals affirmed, holding that Melissa was not liable for breach of contract. The court ruled that because Sharon is named as resident and representative under the admission agreement, Melissa's signature at the bottom of the document "must be read as" Melissa signing on behalf of Sharon and "her signature and initials on the document merely obligated her mother to comply with the terms of the Admission Agreement."

For the full text of this decision, go here.  

Both cases underscore the importance of family members distinguishing their role as "agent" or "attorney-in-fact" when signing nursing home admissions agreements.