Financial Planning for the Possibility of Cognitive Decline/Dementia

 A reader writes in, asking:

“Would you consider writing a column on options for protecting oneself from being taken advantage of in dotage if there are no children to take over the finances? We’ve done wills and named beneficiaries for all accounts. Is there a document or trust or process to hire a trustworthy professional when the time comes?”

Simplify and Automate

Firstly, while this is not exactly an estate planning tool, simplifying your finances (e.g., consolidating accounts, minimizing the number of investment holdings, automating payment of bills, etc.) can help minimize the impact of minor cognitive decline. It also makes things easier for anybody who might take over control of your finances, as discussed below.

Increasing the portion of your spending that is satisfied by automatic, guaranteed sources of income (i.e., Social Security and/or lifetime annuities) is also helpful for similar reasons. That is, once such sources of income are in place, they require no further decision-making — a marked contrast from the ongoing process of selling investment holdings to satisfy living expenses.

Durable Power of Attorney for Finances

A useful tool for planning for the possibility of dementia or other forms of cognitive decline is the durable power of attorney for finances. (Of note: I’m sticking specifically to financial concerns for the sake of this article, but a durable power of attorney for healthcare may be useful as well.) A power of attorney for finances is a document that appoints someone as your “agent” (sometimes referred to as an attorney-in-fact), and this person will have the authority to make financial transactions on your behalf.

A key point is that, in this context, it is critical that it is a durable power of attorney. A non-durable power of attorney automatically expires if you become mentally incapacitated, which is obviously a problem when mental incapacitation is precisely the concern we’re trying to address.

When drafting the power of attorney, it can be an immediate power of attorney (which grants the applicable authority to your agent immediately), or it can be a springing power of attorney (which only “springs” into effect if/when you become unable to manage your affairs due to disability or mental incapacitation). A springing power of attorney is safer in one sense (because it doesn’t grant anybody any authority until it’s necessary), but in some cases it can actually create problems.

There will generally be a specific event that must occur in order for a springing power of attorney to spring into effect (e.g., your physician must sign a document stating that you can no longer manage your own affairs). With dementia, there’s a big hazy area between “clearly mentally capable” and “clearly not mentally capable.” There’s often a stage at which a person is pretty “with it” on some days and much less so on other days. In short, there could be a point at which you could really use help, but your physician is not yet willing to sign that document — so your chosen agent cannot yet step in.

Another important point here is that some financial institutions will require their own power of attorney document to be filled out. (That is, they may not honor the power of attorney document that you and your attorney have prepared.) So be sure to check with your bank(s), brokerage firm(s), and so on in advance to see what they specifically require.

Develop Relationships Now

If you do not have a family member or friend whom you trust sufficiently to appoint to to be your agent, you can appoint a paid professional (e.g., an attorney, CPA, or CFP whom you trust).

Be aware, however, that most attorneys, CPAs, and CFPs do not provide such services, because a) doing so is quite a bit different from the typical services offered by such professionals, and b) taking on the role of being somebody’s agent comes with a considerable list of liability concerns. So don’t just expect your current attorney/CPA/CFP to be willing to take on that role when the time comes.

Instead, you will probably have to find a professional who specializes in this sort of work. Fortunately, such people/firms do exist. For instance, if you live in Chicago, you may want to begin with a search for: “eldercare CPA Chicago” or “professional fiduciary Chicago” (without the quotes).

A Few Final Notes

With regard to planning for potential dementia, if you have a living trust, it’s important to appoint a successor trustee, who can take over in the event of your incapacitation. It’s also important to note that a living trust is not a replacement for a durable power of attorney for finances, because the trustee’s authority is strictly limited to the assets within the trust. And some assets (most notably your retirement accounts while you are still alive) cannot be put in the trust.

Finally, with regard to everything above I would add that:

1. It’s important to address these matters well in advance (i.e., while it is still quite clear to you and everybody else involved that you are still of sound mind), and
2. It’s important to discuss these matters with an attorney who has expertise in estate planning.

https://obliviousinvestor.com/financial-planning-for-the-possibility-of-cognitive-decline-dementia/

CMS Grants Transitional Pass-Through (TPT) Payment for Shockwave’s Coronary IVL

 Shockwave Medical, Inc. (NASDAQ: SWAV), a pioneer in the development of Intravascular Lithotripsy (IVL) to treat severely calcified cardiovascular disease, announced today that the Centers for Medicare & Medicaid Services (CMS) granted approval for a Transitional Pass-Through (TPT) payment for Shockwave C2 Coronary IVL device, effective July 1, 2021. The TPT status provides incremental payment for Shockwave C2 devices used in the hospital outpatient settings.

In the July 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS), CMS issued a new device transitional pass-through code (C1761) for use by hospitals to bill for Shockwave C2 Coronary IVL catheters. In addition, as part of the payment calculation, CMS announced that a customary deduction known as a device offset will not be applied to coronary stenting procedures involving coronary IVL. The Shockwave C2 Coronary IVL device will be eligible for TPT payments for three years.

This announcement comes less than two months after CMS recommended Coronary IVL be eligible for incremental payment via a New Technology Add-on Payment (NTAP) as part of the Fiscal Year 2022 Hospital Inpatient Prospective Payment System (IPPS) Proposed Rule. The intent of both the TPT and NTAP programs are to facilitate Medicare beneficiary access to the benefits of new and innovative devices while cost data is collected for eventual incorporation into the respective payment systems.

The FDA granted the Shockwave C2 Coronary IVL system Breakthrough Device Designation (BDD) in 2019 based on the device’s potential to provide a more effective treatment for life-threatening or irreversibly debilitating conditions when compared to existing treatment options. Since 2020, CMS has provided an alternative pathway for innovative technologies that have received FDA marketing authorization and BDD to quality for device pass-through payment.

https://finance.yahoo.com/news/cms-grants-transitional-pass-tpt-200300812.html

Delta Variant Accounts for 5% of NYC Virus Cases Studied

 The so-called Delta variant, the COVID-19 strain blamed for a devastating viral surge in India that led to a global daily death record of more than 6,000 fatalities this week, now accounts for nearly 5% of positive samples studied in New York City, according to new data from the health department.

The city still classifies that novel strain as a "variant of interest," meaning it has genetic markers associated with higher risks of transmission, reinfection or severe illness, as well as reduced vaccine effectiveness. More study would be needed to confirm it as a variant of concern. The classification for that level requires a body of scientific evidence showing it is more likely to pose any or all of those challenges.

That Delta variant, though, is of paramount concern to national infectious disease expert Dr. Anthony Fauci, who urged state officials this week to reenergize vaccination efforts before that strain becomes more predominant in the U.S. It is already the dominant strain in the U.K. and accounts for 6% of U.S. cases studied.

The actual proliferation in the U.S. is likely higher, though, as the U.S. is running the genetic sequence on a fraction of cases. The same might apply to New York City.

"In the U.K., the Delta variant is rapidly emerging as the dominant variant ... It is replacing the B.1.1.7," Fauci said. "We cannot let that happen in the United States."

The B.1.1.7 strain, the one that first emerged in the U.K. last fall and became the dominant strain in the U.S., is still the most common COVID strain in the five boroughs, health department data show. That variant, called Alpha under the World Health Organization's new naming convention, accounts for 42.9% of recent positive samples studied in New York City and is considered a variant of concern.

The so-called New York City variant, on the other hand, otherwise known as B.1.526 or Iota, accounts for less than a quarter of recent samples studied and does not appear to cause more severe disease than other versions of the virus, nor does it appear to increase reinfection risk, federal and local officials have said.

Also under continuously close monitoring is the P.1 variant, the one first identified in Brazil (now known as Gamma), which accounts for 7.4% of recently tested samples in New York City. That and the Alpha variant are the only two variants of concern with representation above 1% in the city at this point, data shows.

Handout

Here's the latest variant data from the NYC Department of Health.

None of the variants identified in New York City so far have been classified as "variants of high consequence," which would indicate clear evidence that existing prevention tactics, including vaccination, are less effective against them.

There is no indication that any of the positive samples involved in the variant testing involved people who had already been vaccinated for COVID before testing positive. The city does monitor these so-called breakthrough infections but says they account for a minuscule fraction of all cases across the five boroughs.

Existing vaccines are believed to protect against the variants that have emerged and those that will develop over time, which is why Fauci issued the plea to boost U.S. vaccination rates before another COVID wave threatens America.

Right now, more than a dozen states, including New York, are on pace to hit President Joe Biden's goal of at least partially vaccinating 70% of American adults by July 4 but many others will likely fall short, potentially putting the public at risk.

In New York City, where more than 57% of adults are fully vaccinated and nearly 66% have had at least one dose, according to state data, core viral rates are at their lowest levels in a year. The positivity rate has notched multiple all-time lows.

New daily cases are down more than 36% the last seven days compared with the prior weekly average for the last month. Average hospitalizations are down nearly 49% in that time frame while confirmed daily deaths have fallen 42%. The declines between January and June are even more significant, the city has said.

Statewide, New York reported its 14th straight day of record-low COVID positivity on Friday. The rolling rate is 0.47%, a national low, according to Johns Hopkins University. It has declined for 67 consecutive days while statewide hospitalizations are down to 709, their lowest total since Oct. 6, Gov. Andrew Cuomo said Friday.

https://www.nbcnewyork.com/news/coronavirus/delta-variant-accounts-for-5-of-nyc-virus-cases-studied-alpha-still-dominates-data-shows/3100860/

COVID-19 virus can cause diabetes: new studies

 There is troubling news for those infected with the COVID-19 virus. New studies have found that the virus may cause diabetes in addition to pneumonia and other health problems.

Most people will recover from COVID without longer-term problems, but doctors have noticed that some patients go on to develop diabetes.

Now, new research is finding that the virus may infect and destroy certain cells that are crucial for keeping diabetes at bay. Armed with this new knowledge, scientists are now racing to understand how to best prevent this from happening in patients with COVID-19.

Diabetes already contributes to 10-15% of deaths in the United States. In 2017, nearly 34.2 million people, or 10.5% of the U.S. population, had diabetes. Per data from the Centers for Disease Control and Prevention, approximately 1.5 million Americans are diagnosed with diabetes every year. Of those with diabetes, nearly 1.6 million Americans have type 1 diabetes, an autoimmune disease that attacks pancreatic beta cells to reduce insulin production.

“There is a difference between type 1 and type 2 diabetes,” said Dr. Jennifer Ashton, ABC News' chief medical correspondent and a board-certified OBGYN, who was not involved in the studies. “[In] type 1 diabetes, the body does not make enough insulin. In type 2, there is enough insulin but it is not working properly.”

As insulin causes cells to take up sugar in the blood, a decrease in insulin production or a resistance to insulin causes high levels of sugars or glucose in the blood. This high level of glucose, termed hyperglycemia, is the hallmark of diabetes.

“Earlier lab studies had suggested that [the COVID-19 virus] can infect human beta cells,” said Dr. Francis Collins, the director of the National Institutes of Health, said in a recent blog post. “They also showed that the dangerous virus can replicate in these insulin-producing beta cells to make more copies of itself and spread to other cells.”

New research from Stanford University School of Medicine and Weill Cornell Medicine confirmed the association between COVID-19 and diabetes. By analyzing autopsy samples from people who died of COVID-19, both studies illustrated the virus’s ability to infect pancreatic beta cells, decrease insulin secretion and effectively yield type 1 diabetes.

“The virus actually destroys the cells in the pancreas that make insulin,” said Ashton. “[This] decreases insulin levels and then leads directly to high sugar and type 1 diabetes.”

Experts say these particular cells may be especially vulnerable to being attacked by the virus as they contain certain receptors known to bind to COVID-19.

Once invaded, these cells were transformed into different types of cells with a lower expression of insulin. According to experts, this shows that SARS-CoV-2 could change the fate of a cell.

Encouragingly, one study showed that specific drugs might be able to reverse this fate. Those findings will need to be confirmed in larger, more rigorous studies, researchers say.

Unfortunately, the virus might damage the pancreas and cause diabetes in ways that aren’t as easily reversed with medication. Due to the destruction of pancreatic cells, patients could potentially become dependent on diabetes medications, such as insulin, long after they finish their battle with COVID-19.

“More study is needed to understand how SARS-CoV-2 reaches the pancreas and what role the immune system might play in the resulting damage,” said Collins.

Both works highlight the possibility of COVID-19-induced diabetes and stress the need for awareness in those infected with the virus.

“The key is if you are diagnosed with COVID-19 and have any classic signs or symptoms of type 1 diabetes, get tested for diabetes,” said Ashton.

Anyone who has recovered from COVID-19 should be on the lookout for symptoms of diabetes, Ashton added.

“We’re talking about extreme thirst and increase in urination, unintentional, significant weight loss, or fatigue, just to name a few,” she said.

Added Collins: “This work provides yet another reminder of the importance of protecting yourself, your family members, and your community from COVID-19 by getting vaccinated if you haven’t already -- and encouraging your loved ones to do the same.”

https://abcnews.go.com/Health/covid-19-virus-diabetes-studies-find/story?id=78168634

New treatment demonstrated for people with vaccine clots

 

A new lifesaving treatment for people suffering from vaccine-related blood clots has been demonstrated by scientists of the Faculty of Health Sciences.

Researchers at the McMaster Platelet Immunology Laboratory (MPIL) are recommending two treatments, a combination of anti-clotting drugs with high doses of intravenous immunoglobulin, to combat vaccine-induced immune thrombotic thrombocytopenia (VITT).

The treatment’s effectiveness was described in a report describing three Canadian patients who received the AstraZeneca vaccine, and who subsequently developed VITT. Two suffered clotting in their legs and the third had clots blocking arteries and veins inside their brain.

“If you were a patient with VITT, I’d be telling you we know of a treatment approach. We can diagnose it accurately with our tests, treat it and we know exactly how the treatment works,” said Ishac Nazy, scientific director of the lab and associate professor of medicine.

VITT occurs when antibodies attack a blood protein, called platelet factor 4 (PF4), which results in activation of platelets in the blood, causing them to clump together and form clots. Blood samples taken from the patients after treatment showed reduced antibody-mediated platelet activation in all cases.

While the study patients were older, many VITT cases have affected younger people. However, Nazy and his MPIL colleagues said VITT is a rare disorder, regardless of people’s age.

The lab’s scientists include professors of medicine Donald Arnold and John Kelton and professor of pathology and molecular medicine Ted Warkentin. Together they devised an effective VITT test and treatment by building on their previous investigations of heparin-induced thrombocytopaenia (HIT).

While the two conditions are similar, using a standard HIT antibody test to detect VITT can yield false negative results.

This led the scientists to modify the HIT test to detect VITT-specific antibodies that are found, albeit rarely, in patients who had a COVID-19 vaccine.

Subsequent lab tests on patient blood samples showed how high doses of immunoglobulin coupled with blood-thinner medications shut down platelet activation and stopped clot formation.

“We now understand the mechanism that leads to platelet activation and clotting,” said Nazy.

The study was published by the The New England Journal of Medicine. External funding for the study was provided by the Canadian Institutes for Health Research.

https://brighterworld.mcmaster.ca/articles/new-treatment-demonstrated-for-people-with-vaccine-clots/

Over half of adults unvaccinated for COVID-19 fear needles – what’s proven to help

 If you’re among the 25% of Americans averse to needles, you’re probably not surprised by the COVID-19 immunization stall. Even for those who want immunity, bribes with beer or lottery tickets may not be enough to override anxiety made worse by pervasive images of needles in the media.

As a physician specializing in pain management, I study the impact of pain on vaccination. Research-proven adult interventions for pain, fainting, panic and fear can make vaccination more tolerable. At a minimum, understanding the reasons needle fear has become common might make the embarrassment easier to bear.

Why needle anxiety has increased

Needle fear has increased dramatically since a landmark 1995 study by J.G. Hamilton reported that 10% of adults and 25% of children feared needles. In that paper, adult patients who remembered when their fear began described a stressful needle experience around age 5.

The childhood experiences of the patients usually related to an unexpected illness; at the time the Hamilton participants were in preschool, vaccines were scheduled only until age 2. For most people born after 1980, however, booster injections given between ages 4 to 6 years became a routine part of the vaccine experience. The timing of boosters maximizes and prolongs immunity, but unfortunately falls within the age window when phobias form. A 2012 Canadian study of 1,024 children found that 63% of those born in 2000 or later now fear needles. In a 2017 study, my colleagues and I confirmed this increase in prevalence: Half of preschoolers who got all their boosters on one day – often four or five injections at once – were still severely afraid of needles as preteens.

Unsurprisingly, needle fear affects how willing teens and adults are to get vaccinated. A 2016 study found needle fear to be the most common reason teens didn’t get a second HPV vaccine. Health care workers are no exception: A 2018 study found that 27% of hospital employees dodged flu vaccines due to needle fear. And most recently, an April 2021 national survey of 600 not-yet-COVID-19-vaccinated U.S. adults found that 52% reported moderate to severe needle fear.

Potential solutions for adults

For children, evidence shows that addressing their fear and pain while distracting them from the procedure is most effective in reducing distress.

While adults are not just big children, combining these concepts with findings from available adult injection studies suggest a few potential interventions. For the many who want a vaccine but need some support, here’s what we know:

1. Pain reduction

Relieving injection pain may reduce needle fear by giving patients a feeling of control. For example, a group of patients in New Zealand were repeatedly missing their monthly antibiotic injections for rheumatic heart disease. Their doctors created a special clinic, offering either anesthetics, a vibrating cold device or both during the shot. The interventions in 107 adults reduced pain and fear by 50% after three months. Six months later, half the patients still used the interventions, and the special “missed dose” clinic was no longer needed.

Specifically for vaccination, applying a vibrating cold device to the injection site a minute prior to injection, then pressing just above the site during injection, relieved pain and improved satisfaction for adults, and was most effective for those with needle fear. A horseshoe-shaped plastic device using sharp prongs to confuse the nerves also reduced injection pain but increased anxiety, possibly due to discomfort from the prongs themselves.

Cold spray doesn’t help reduce vaccination pain for children, but has been shown to be more effective than topical anesthetics for adult injections.

2. Psychological therapy

Exposure-based therapy involves asking a patient to rank anxiety caused by parts of a procedure, like seeing a picture of a tourniquet or thinking about sharp things, and gradually exposing them to these parts in a controlled environment. Free self-guided resources are available for fears ranging from flying to spiders. However, none of the three studies testing this approach on adult needle fear showed long-term fear reduction.

One of the studies that taught techniques to reduce fainting, however, was considered a success. Fainting, or vasovagal syncope, and needle fear are often conflated. While passing out due to injections is more common with anxiety, it is often a genetic response. Tensing the stomach muscles increases the volume of blood the heart can pump, keeping blood in the brain to prevent lightheadedness during needle procedures.

3. Distraction

Surprisingly, there are no studies on adults using distraction for injections. Two studies, however, have found that pretending to cough reduces pain from blood draws.

Dropping F-bombs could also help: A recent study found that swearing reduced pain by one-third compared to saying nonsense words. Distraction with virtual reality games or videos has been shown to be more effective in children, although there have been mixed results in adults.

Mentally engaging tasks may also help. A visual finding task given to children during intramuscular shots has been shown to reduce pain and fear, with 97% rating the experience more pleasant than previous blood draws. Adults may need a more complicated task, but a similar intervention could work for them as well.

Use multiple interventions and go in with a plan

To reduce needle fear, research suggests the more interventions, the better. A 2018 study summarizing research on vaccine pain concluded that patient-operated cold and vibration devices combined with distraction techniques were most effective. Canada has implemented a practical national needle fear intervention for their vaccine rollout, emphasizing preparing ahead to help make vaccine day more comfortable.

Adults who don’t like needles are in the majority. Taking control of your vaccination experience may be the best way to combat needle anxiety.

https://theconversation.com/over-half-of-adults-unvaccinated-for-covid-19-fear-needles-heres-whats-proven-to-help-161636

NY-Presbyterian to mandate COVID-19 vaccinations for staff

 The NewYork-Presbyterian hospital system will require all of its 48,000 employees to be vaccinated against COVID-19 unless they have a valid exemption, hospital officials announced Friday.

“As a leading health care organization, we believe it is essential to require vaccinations to protect our patients and ourselves against the threat of further harm from the pandemic and the possibility of more dangerous mutations,” Dr. Steven Corwin and Dr. Laura Forese, the president and executive vice president of the 10-campus hospital network, said in an email to staff.

Employees will be required to receive their first vaccine dose by Sept. 1, the officials said, with applications for medical or religious exemptions due Aug. 1.

About 70% of the network’s employees are now vaccinated, a spokesperson said.

NewYork-Presbyterian appears to be the first health care network in the state to mandate vaccinations for staff.

Kenneth Raske, the president of the Greater New York Hospital Association, said he supports the requirement.

Raske said in a statement that every health care organization wants a fully vaccinated work force, “and some may choose to emulate the mandatory approach.”

NewYork-Presbyterian’s decision to require vaccinations comes as other hospital systems around the country are moving to impose vaccine requirements.

The Houston Methodist system suspended 178 employees this week for refusing to abide by its mask mandate. Houston Methodist’s president, Dr. Marc Boom, said in a statement that he wished the number of staff members declining vaccinations without a valid exemption were zero, “but unfortunately, a small number of individuals have decided not to put their patients first.”

https://apnews.com/article/nyc-state-wire-ny-state-wire-coronavirus-pandemic-health-f823685f9f3f78a8413c75e84cfde44c