“It took my mother having a stress-related heart attack before we quit dismissing my father’s progressing dementia to ‘senior moments’ and got him a proper diagnosis of Alzheimer’s. Had we paid attention to the warning signs of this disease, a lot of prevention could have been in place.” — Brent

Know the 10 Signs of Alzheimer'sThere seems to be a blurred line between “getting old” and early warning signs of dementia or Alzheimer’s.   When does forgetting a word more often become a “problem” or a warning sign of more profound changes?  At the Alzheimer’s Association, we have a list of “10 Warning Signs” that we use as a guide to see if a visit to a physician may be needed (for more information, visit http://alz.org/alzheimers_disease_know_the_10_signs.asp).

  1. Memory loss that disrupts daily life
  2. Challenges in planning or solving problems
  3. Difficulty completing familiar tasks at home, at work or at leisure
  4. Confusion with time or place
  5. Trouble understanding visual images and spatial relationships
  6. New problems with words in speaking or writing
  7. Misplacing things and losing the ability to retrace steps
  8. Decreased or poor judgment
  9. Withdrawal from work or social activities
  10. Changes in mood and personality

When I talk to people about these warning signs, many of them say “Oh! I have all of these… does that mean I have dementia??” Not to worry, yet!  These warning signs are just a hint that it may be time to go visit a doctor and talk about the symptoms you are facing.  A lot of people don’t realize that there are reversible types of dementia, such as thyroid issues, that may cause some of these symptoms.  Going to talk to a doctor can determine the cause of these symptoms and some may actually be reversed.

A lot of these “warning signs” seem like typical age related changes.  However, there is a difference between forgetting where you parked your car and finding it a few seconds later (typical aging) and not remember what car you have (a warning sign of dementia).  Another example is confusion with time or place, again, there is a difference between thinking it is Friday when it is actually Thursday (we’ve all done that!) but remember it is Thursday a few minutes later, versus  thinking it is Summer when it is actually Winter (warning sign).

Where do you think we draw the line between “normal” aging and the beginning signs of dementia?  Even though we have these outlined signs, it may be difficult to tell.  When it doubt, I say talk to your doctor about changes so they can be recorded and monitored in the future.

Reference: www.alz.org/texas

Our Guest Blogger this week is Krista Dunn, MPH, Galveston/Bay Area Outreach Coordinator for Alzheimer’s Association Houston and Southeast Texas Chapter.

Join us for a real-time discussion about the questions raised by this essay on Tuesday from 12:00 p.m. to 12:45 p.m. See Discussion and SL tabs above for details. Link to the virtual meeting room: http://tinyurl.com/cjfx9ag.


holding handsRonald Crossno recently published an opinion piece in the Austin American Statesman (8-28-13) about several bills in Congress aimed at increasing the number of healthcare professionals trained to provide hospice services. The bills are: Palliative Care and Hospice Education and Training Act (H.R. 1339 and S. 641) and Patient Centered Quality Care for Life Act (H.R. 1666). These bills, if passed, would provide Federal support for training and various other activities aimed at increasing the availability of palliative care.

These are excellent initiatives and hospice is a most excellent concept. Let’s say that I agree with 98% of the purposes of these bills, but in the back of my mind is a question. One large goal of these bills, and by inference the healthcare providers who support them, is the expansion of specialty training for physicians and other service providers.

I think we do the overall effectiveness and affordability of healthcare a disservice by creating specialties where the specialty is focused on what, as is the case with palliative care, should be every healthcare providers concern.

I agree, we need highly specialist surgeons who can operate sophisticated robots to do delicate brain surgery on the small segment of the population who needs such skills. However, on the other hand, palliative care and hospice seem to be more in the category of what everybody needs to do as routine and integrated practice. I would rather see these two bills focusing on 1) undergraduate medical and other entry-level healthcare education and 2) the integration of palliative care into the basic mindset of all providers and consumers.

We tend to create these specialized training programs, that produce specialists, who then need a specialized center to offer the service. We then work for years to get insurance and government to pay for it, and in the end, spend twenty or thirty years maintaining this specialized structure that, perhaps, ever so slowly, diffuses into general practice. The end goal can get lost in the day-to-day. For example, hospice, developed by Dame Cicely Saunders in England in the 1960’s, is still not a part of everyday care, as evidenced by the existence of the two bills above, after half a century.

I realize there is a tradeoff when trying to make a new idea (hospice, for instance) common practice. One needs advocates and people skilled in the practices. However, creating specialties where the need is unwarranted just increases training costs, adds more bureaucracy to licensure, and creates specialized practice niches that add additional costs to the consumer.

I do think we need to have long range strategies when developing new ideas and methods that have as the end goal making services widely available, easily accessible and highly affordable. To date, we tend to do just the opposite.

Join us for a real-time discussion about the ideas raised by this essay on Tuesday from 12:00 p.m. to 12:45 p.m. See Discussion and SL tabs above for details. Link to the virtual meeting room: http://tinyurl.com/cjfx9ag.

Reference and Resources

  1. Crossno, R. Congress can improve patients’ quality of life. Austin American Statesman, Editorial, Aug. 28, 2013. http://www.mystatesman.com/news/news/opinion/crossno-congress-can-improve-patients-quality-of-l/nZcmh
  2. American Academy of Hospice and Palliative Medicine.
    Ronald Crossno’s blog at the AAHPM: http://www.aahpm.org/apps/blog/?author=165
    Academy web site: http://www.aahpm.org
    Consumer web site: http://www.palliativedoctors.org
  3. History of Hospice, National Hospice Foundation web site:   http://www.nationalhospicefoundation.org/i4a/pages/index.cfm?pageid=218

Image Source: http://www.stlouis.va.gov/services/Palliative_Care.asp

Patients and families generally love hospice care. The nurses and social workers who are the most frequent providers of hospice care are usually highly enthusiastic as well. So are there any issues with this beloved process? Let’s look at a few aspects of hospice care and the agencies that provide it. First let’s define hospice.

“Hospice got its start in the 1960s as a social movement. Volunteers, often meeting in schools and church basements, organized care so patients could die at home with loved ones, instead of at the hospital laced with tubes. Dame Cicely Saunders, the pioneering English physician who opened St. Christopher’s Hospice in London in 1967, fought traditional methods of unconditional resistance to death, and brought the concept to U.S. shores” (Waldman).

According to Jeanne Dennis, Director of Visiting Nurse Service of New York Hospice Care, “Hospice is a program that provides care for the terminally ill at home or in a facility. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional and spiritual needs of the patient, as well as providing bereavement support to the family. Hospice, which is covered by Medicare and commercial insurance, is available when the patient’s physician determines that further treatment will not cure or reverse the disease, and that the disease at its current stage typically claims life within six months. The care that hospice provides is palliative, focusing on relieving pain and other symptoms but not seeking to cure the disease.”

Beginning as a charity work, hospice has through the evolution of third-party payers and Medicare, developed a for-profit business model. Peter Waldman said, “As hospice care has evolved from its charitable roots into a $14 billion business run mostly for profit, patients like Covington and their families have paid a steep price, according to lawsuits and federal investigations. “ The Covington family is suing a for-profit hospice with charges of elder abuse and neglect. Other for-profits have been accused of paying bounties for referrals and of rewarding employees for finding patients with longer expected survival times.

“The average for-profit patient costs the government $12,609, 29 percent more than a non-profit patient, because the for-profits find people who live longer, frequently at nursing homes … Of the hospices with two-thirds or more of their patients in nursing homes, 72 percent are for-profits.  … Patients stay an average of 98 days in for-profit hospices versus 68 days at non-profits, which have a 0.2 percent profit margin, according to Medicare. The margin at for-profits is 50 times higher at 10 percent. ”

“Medicare’s reimbursement system may spur [for-profit hospice] companies to select patients who need “fewer skilled services” or longer hospice stays because the federal insurance program for the elderly and disabled pays a fixed daily rate, regardless of the services patients need,” cited Molly Peterson.

That for-profit hospice companies are attracted to the bottom-line appears widely accepted. A recent OIG report states, “Medicare currently pays hospices the same rate for care provided in nursing facilities as it does for care provided in other settings, such as private homes.  … The current payment structure provides incentives for hospices to seek out beneficiaries in nursing facilities, who often receive longer but less complex care. To lessen this incentive, the OIG recommends that CMS reduce Medicare payments for hospice care provided in nursing facilities … “ (Levinson).

Commenting on the role of the non-profit hospice service, Amy Ziettlow said, “The Glasswing Butterfly comes from Central America and is often found in regions spanning from Mexico to Panama. It’s quite common in its zone, but it is not easy to find because of its transparent wings. Rainforest ecologists say that the presence of this rare tropical gem is an indication of high habitat quality; its demise alerts them of ecological change. … As a non-profit hospice provider, we free our staff to serve unnoticed, to be transparent butterflies. Our local community profits when our non-profit hospice serves it well. The existence of a non-profit hospice, like the existence of the Glasswing Butterfly, indicates a high habitat quality in our community.”

Ziettlow speaks like a prophet singing the praises of a worthy activity blessed by the spirits.  But like the dinosaur and due to competition from the for-profit hospice, might the lovely and high flying non-profit hospice service fade away? And would that indicate ecological change towards a lowered habitat quality in our community?


Dennis, Jeanne. Hospice Straight Talk: Myths Meet Reality. Huffington Post, July 28, 2011. http://www.huffingtonpost.com/jeanne-dennis/hospice-myths_b_903728.html?icid=main%7Chtmlws-main-n%7Cdl3%7Csec3_lnk3%7C220511

Levinson, Daniel R., DHHS Office of the Inspector General. Medicare Hospices That Focus on Nursing Facility Residents, OEI-02-10-00070, July 21, 2011.  http://oig.hhs.gov/oei/reports/oei-02-10-00070.pdf

Peterson, Molly. For-Profit Hospice Companies May Gain on Fewer Cancer Patients. Bloomberg, February 1, 2011.  http://www.bloomberg.com/news/2011-02-01/for-profit-hospice-companies-may-gain-on-fewer-cancer-patients.html

Waldman, Peter. Preparing Americans for Death Lets Hospices Neglect End of Life. Bloomberg, July 21, 2011. http://www.bloomberg.com/news/2011-07-22/preparing-americans-for-death-lets-for-profit-hospices-neglect-end-of-life.html

Ziettlow, Amy. Non-Profit Hospices: On the Road to Extinction? Hoffington Post, February 10, 2011. http://www.huffingtonpost.com/rev-amy-ziettlow/nonprofit-hospices-on-the_b_819909.html