Friday, November 10, 2017

What Nobody Wants to Think About...


Sognfjord, Norway

Today's topic is one that is difficult to think about, but very necessary in order to go into the future with confidence:  Who will make decisions for you if you cannot?

Nobody has a crystal ball, so we don't know what kind of challenges may be up ahead.  Maybe you'll get really lucky and stay reasonably healthy, cognitively intact, and able to make your own decisions until you are quite old, and then have a short, precipitous decline...that's the best case, I think.  Not quite as desirable is a period of illness, but with cognitive abilities intact.  And, of course, nobody's first choice is gradual intellectual decline.  Somehow, we have to plan for all of those contingencies.  

Let's be honest, this is about maintaining control of outcomes, and if you don't make serious plans, you are actually choosing to roll the dice.  For example, if you don't have advanced directives the default is for medical professionals to do everything they can to save your life, regardless of the outcome.  That may be your wish, but if it is not, if you do not want to be maintained on life support when there is no possibility of recovery, it will happen anyway.  Regarding your finances, if you don't designate someone to act in your best interest should you become incapacitated, eventually a court appointed guardian will be appointed to do so, but it is also possible that someone could exploit your resources before that happens.

So, how do you choose the person or persons who will be able to make decisions for you if you are no longer able to do so?  Let's consider health care advanced directives first.  It is important that the person you designate lives near you, since they may be needed in an emergency.  It should be someone that you have discussed your wishes with, and ideally that person shares your views on how much medical care you wish to have under different circumstances, or at the very least, is willing to honor your wishes.  Who might this be?  It may be an adult child, and if you have several children, it may be possible to name more than one, or one to back up the other, which spreads the responsibility around somewhat.  

But what if, for a variety of reasons, your children are not a good choice or you do not have children or other relatives who could take on this responsibility?  Or let's say your family members have a different view of how much medical intervention is desirable.  You may want no extraordinary measures taken because you feel you are at the end of a good long life, but your family may want everything done because they are not ready to let you go. We have seen situations where there have been complicated relationships between parents and children that make it difficult to either discuss this issue or to rely on children when the time comes.  Or what if you have always been an independent, autonomous person, and you don't want to burden your children with making these decisions for you? 

Sometimes trusted friends are a better choice than family.  The nature of a peer relationship makes it easier to discuss such sensitive issues, although it may be necessary to choose someone somewhat younger (or at least healthier) than you are to ensure the arrangement endures for your lifetime.  When thinking about who to ask to take on this important responsibility, we suggest you look for someone who has the emotional strength necessary, and ideally someone you have known for a very long time.  What you are really looking for is someone who has no other agenda and no personal stakes in the outcome.  In other words, you can count on them to do what you want.  

We have known people to enter Continuing Care Retirement Communities as a way to not be a burden to their children.  And this does work, in a certain way, as the facility will take over to make decisions.  However, it is also true that the facility may have its own agenda that can subtly drive those decisions, as we've mentioned in previous posts (See:  Thinking About What Comes Next, 3/15/16).

Remember when Judy's mother was alive we had a Geriatric Care Manager who also had Medical Power of Attorney when we were out of town?  In the end, that allowed her to accompany Avis in the emergency room, and she was familiar with her wishes.  This worked for us, in part, because Judy had worked with the woman for many years and trusted her.  If there is a trusted professional that you have a long relationship with, whose honesty you have seen demonstrated, and who has no investment in the outcome other than honoring your wishes, it would be possible to designate them to make decisions for you.  

The financial issues are definitely more complex, just because of human nature.  One of the reasons that my mother chose me to be her Financial POA is because she knew that I did not need the money.  She also knew my philosophy, which was that the money was there for her use, and I encouraged her to spend it for her own comfort, not to try to preserve the estate.  These are questions you can ask yourself about whomever you are considering for this role:  Is this someone whose judgment in money matters matches mine?  Do I have confidence that this person will watch out for my best interests?  You will be asking the person to take on a responsibility, so is this someone who would not mind doing that?

What if you feel you do not have anyone you can rely on fully when it comes to managing your money or who might be overburdened by the responsibility?  When I think of an ideal arrangement for someone who wants peace of mind about what will happen should they be incapacitated I'm unfortunately reminded of the many cases I saw where someone was exploited.  It makes me wary of the motives of those who might be seen as the obvious people to turn to, such as attorneys and accountants, and even in some sad cases, family members or paid caregivers.  

I struggled to come up with a recommendation. What I have come up with may be a little more complicated than just naming someone as your Financial Power of Attorney, but it may also provide a little bit of a safety net.  I would suggest that perhaps the same person you have turned to for Power of Attorney for Health Care could be designated to supervise a bookkeeper or accountant who would take over the day-to-day finances.  That way you are not overburdening your friend or relative with the bill-paying, and the POA for Finances (your friend) can keep an eye on the overall financial situation (including investments and savings).  Likewise, the bookkeeper or accountant could make sure money is handled in appropriate ways. I would suggest monthly statements from the bank and other financial institutions go to both the bookkeeper and the POA.  It is very important to choose someone you trust for both positions.  You also gain the added security of not relying just on one person, but having a second person for oversight. 

Your goal is to set up a solid safety net so that you are cared for medically and financially in the way you wish, allowing for all of the possibilities and unknowns.  Then, once you have it set up, you can go back to not thinking about it and hope that you never have to exercise those options.  

That's what we're doing.



















Tuesday, October 31, 2017

The Kindness of Strangers? How People Want to Separate You from Your Money

From the Summer of Love Exhibit at the DeYoung Museum in San Francisco

As we all know, there are scam artists, conmen (and women) and sleazy contractors and businesspeople out there, hoping to make a fast buck.  We're all vulnerable to some extent, but as we get older, we can become much more of a target.  It may be a combination of seniors having more assets, and at the same time, not being quick enough to recognize a fraudulent pitch.  By some estimates, 10% of all older people experience financial fraud.

We recently read an article in The New Yorker about a truly nightmarish situation, where private guardians in Nevada with the collusion of some health care professionals and possibly also people working in the courts gained control of older people’s estates.  People were literally seized in their homes and moved into assisted living.  Their homes and possessions were sold off and the guardians used high fees to siphon off money from their estates.  Often, the reason guardianship was awarded was for dubious or trumped up reasons, and the people involved were not present during the court proceedings and were not allowed to have their own counsel.  Their efforts to regain control of their estates were re-buffed by the courts and even their children’s efforts to take over guardianship were brushed aside.   This was plain and simple theft.  Some of the perpetrators have now been indicted, but the damage has been done to perhaps hundreds of people.

This is one of the most outrageous scams that we have heard about.  Most states require an older person to appear in court and to be represented by an attorney in any guardianship proceeding.  Furthermore, the court would require an evaluation by an independent expert to determine the person’s capacity to make their own decisions, but that was not the case in Nevada.  The Nevada legislature is currently working on a law that will give people the right to have legal representation in guardianship cases.  But even in states with more protections, abuse by guardians is frequent.   An organization called Americans Against Abusive Probate Guardianship (aaapg.net) has been formed to publicize abusive situations and to advocate for changes in the law that provide more protections against improper use of guardianship.

One way to protect yourself is to give a trusted friend or family member power of attorney.  This is widely recommended by legal experts so that someone can act in your behalf in the event you are no longer able to manage your own financial affairs or make medical decisions.  We will write another post addressing this particular issue.

Separating people from their money has gone on forever, but since the economic meltdown in 2008, there has been increasing focus on the actions of financial advisors and their investment firms that dumped risky investments like bundled mortgage securities on their clients, and then walked away with the profits, while their customers took the loss.  Another strategy used by financial advisors is to put clients into investments where the advisor or his/her firm makes a bigger profit, rather than what would be the best investment for that person. 

Accusations have recently been raised that an investment company that had a reputation for integrity, TIAA (Teachers Insurance and Annuity Association), had embarked on a path of doing what’s best for the firm and not for its clients.  In an October 21 article, The New York Times summarized allegations by former employees that TIAA had been encouraging clients to move their funds from low fee, self-managed accounts into managed accounts without revealing that the investments have higher fees.  Additionally, it was reported that employees had to meet quotas for how many investors were signed up for these funds.  


To address these types of questionable activities, President Obama issued an order that required investment firms to work in their client’s best interest.  President Trump recently rescinded those regulations.  When people handle money, there is always temptation.  Without rules or oversight, it’s a jungle out there. 

Of course, there are also the everyday scams, door-to-door trolls looking to sell something they won’t ever deliver or that costs more than its true value, as well as telephone, email and other electronic media scams.  Have you received this call? The caller identifies himself as with the Internal Revenue Service and says you owe money at will be fined or go to jail unless you pay.  AARP posts information on various scams at https://www.aarp.org/money/scams-fraud/info-2017/imposter-scams-con-man.html?intcmp=AE-MON-BB-LL2.  The bottom line is don’t give anyone over the phone or by email any financial information, including charities.  Go instead to verified websites.

For more information:

“How the Elderly Lose Their Rights, The New Yorker.  https://www.newyorker.com/magazine/2017/10/09/how-the-elderly-lose-their-rights

“The Finger-Pointing at the Finance Firm TIAA,”  The New York Times, https://www.nytimes.com/2017/10/21/business/the-finger-pointing-at-the-finance-firm-tiaa.html?_r=0


Tuesday, October 24, 2017

Time, Family, and Baseball

1982

You may have read on my Facebook page the posting from my son, Ben, who pushed the friendly baseball rivalries in our family with this question, “My father has a chance to use sports to determine which of his children he loves the best. On one side, it's me and the Chicago Cubs and on the other, Matt Zarit and Tom Weston rooting for the Dodgers. Cubs vs Dodgers to determine which of his children are his favorite.”  Of course, I love all my children, and so I flippantly answered that I would root for the team in blue—both teams wear blue!  But his question led me to think about how baseball and family have been intertwined throughout my life.

I grew up as a White Sox fan.  It was logical.  We lived on the South Side of Chicago and my father was a White Sox fan, though my sister, Marian, was and still is an ardent Cub fan.  During my formative years in the 1950s, the White Sox were the more dynamic team.  They had signed African American and Hispanic players like Minnie Minoso and Luis Aparicio, who made the Sox competitive in the American League.  The Cubs in the early 1950s had entire outfields of plodding, past-their prime sluggers, who were best suited for Designated Hitter, if only it had existed then.  When the Cubs finally broke the color barrier, they signed one of the greatest players I have ever seen, Ernie Banks.  Banks single-handedly carried the Cubs to respectability.  I enjoyed going out to Wrigley Field a couple of times every summer to watch Banks and some of the other exciting players they were bringing in.  All the games were played in the daytime at Wrigley then, so my friends and I could take the “L” across town and sit in the sun with a few thousand other fans.  But I remained a Sox fan first and foremost.

The baseball highpoint of my childhood came in 1959.  After finishing behind the hated Yankees and the Indians for the whole decade, everything came together for the Sox, and they won the pennant.  It was the first World Series in Chicago since 1945 when the Cubs had lost to Detroit, and the first appearance for the Sox in the World Series since the infamous “Black Sox Scandal” in 1919 when several players on the team conspired with gamblers to throw the series.  In 1959 Bill Veeck was owner of the team and one of the most creative people ever in baseball.  Veeck, knew that the demand for tickets from long-suffering Sox fans would be tremendous, so he created a lottery.  My father and I filled out a postcard, sent it in, and we got two tickets for the first game of the Series.  I was so excited. The Sox won the game, beating the Dodgers 9 to 0, though ultimately losing the Series 4 games to 2.  But what could be better in a boy’s life than to go with his Dad to a World Series game.

In the 60s, the Sox quickly returned to mediocrity, but the Cubs built an exciting team with talented players like Billy Williams and Ron Santo.  In 1969, they were running away from the rest of the league and it looked like they would finally return to the World Series.  I remember going to a game with my Uncle Irv to see the Cubs play the Mets in August.  Wrigley was full and there was tremendous excitement, but the Cubs lost that day.  And continued losing.  The Cubs manager, Leo “the Lip” Durocher began celebrating his genius as a manager in mid-August for leading the league, and he disregarded the Mets with their young pitchers-- Jerry Koosman, Tom Seaver, Nolan Ryan and others.  The Mets caught the Cubs.  Cub fans everywhere were heart-broken.  I was disappointed, too.  I had loyalty to the Cub fans in the family and besides, I will root for any Chicago team over any New York team.

I moved to LA in the mid 70s, but didn’t pay much attention at first to the local teams. After Judy and I married, I found myself with two stepsons, Mike and Tom, who were enthusiastic Dodger fans, and so we started going to Dodger games.  Ben came along a lot of the time.  Those were great teams—Steve Garvey, Davey Lopes, Mike Piazza, Pedro Guerrero, Ron Cey and Fernando Valenzuela among others--and Dodger Stadium is a beautiful place to see a game.   The house was filled with baseball cards and discussions of baseball statistics.  After Matt was born, we took the first photo of him with his 4 siblings, all wearing Dodger shirts. That's the photo at the top of the blog.

When we moved to Central Pennsylvania, we continued our allegiance to the Dodgers, going to see them occasionally in Pittsburgh and Philadelphia. In 1988, we followed the Dodgers path to the World Series.  Gathered around the TV, we all watched as Dodgers' manager Tommy Lasorda sent injured star Kirk Gibson up to bat in the 9th inning of game one of the World Series.  Gibson was facing the best relief pitcher in baseball, Dennis Eckersly, and he winced in pain when he swung and missed a couple of pitches.  Then he hit an improbable home run to win the game.  The memory is still quite vivid.  Of course, that’s because Tom periodically pulls out the DVD from that game so we can watch Gibson’s homer again.  It was a shared experience, one of many though perhaps the most dramatic, that became part of our language and mythology as a family.

Ben has become a fervent Cubs fan, particularly after he moved to Chicago in the late 1990s and began going to games regularly.  Megan has never taken sides in the family baseball passions and after she moved to Nashville, she became an ardent football and hockey fan.  The Sox and Cubs, meanwhile, continued their futility.  The low point was the 2003 Bartman game, which helped keep the Cubs out of the World Series once again. I kept my allegiance to the Sox, hoped for the best for the Cubs, followed the Dodgers though less often, and discovered the magnificent new ballpark in Pittsburgh. 

Recently, the New York Times ran an op-ed piece entitled, “What the Cubs Could Teach the President.”  (https://www.nytimes.com/2017/09/30/opinion/sunday/cubs-baseball-trump.html?_r=0)  The author argued the virtues of being a Cubs fan—lack of hubris, able to take a long-term view, having a sense of history.  Like many stories about the long-suffering Cubs fans, the author neglected to mention that there was another team in Chicago with long-suffering fans.  And he failed to mention that in 2005 an obscure State Senator from the South Side of Chicago threw out the ceremonial first pitch in game two of the league championship series.  The White Sox won the game and the next seven straight for the first World Series champion in Chicago since 1917.  I was walking on air.  I never thought I would ever see the Sox win.  Ben said afterward that I was not allowed to complain about the White Sox for 5 years, which was sage advice.  And the obscure State Senator and Sox fan from the South Side, Barak Obama, became a very good President.

For the last several years we have had a minor league team in State College, the Spikes.  It has been a perfect place to take grandchildren—the seats are close to the field, it’s a short walk to get more food and there is a lot of entertainment. Brian got a ball at one game.  Sam sang “Take Me Out to the Ballgame” along with the crowd even before he had any idea what was going on in the field.  Lucy loved the fireworks after the game.  Andrew loved the food.  Liam has yet to visit when the Spikes are playing, but we look forward to taking him to a game. The kids even watch the game on occasions.

Last year was the Cubs’ year.  I rooted for them.  I had to.  I knew what it meant to me to see the Sox win, and I wanted the same for Ben, Marian, and the other Cubs fans in the family.  I was happy when they won. 

That was last year.  Ben, I’m happy the Dodgers won this year, but I certainly would have rooted for the Cubs in the Series if they had made it.


For people who are not baseball fans, the fascination may hard to understand.  People complain baseball is slow, and it is.  But it is complex.  The game’s strategies around pitching, hitting, and fielding, and what player moves to make during a game are a source of endless conversation, as is the abundance of statistics generated.  The almost daily games build familiarity with the players and loyalties to the local team.  Judy enjoyed baseball most when the boys were young, because she got to know about the players from them. Baseball becomes a source of conversation in the family that transcends any conflicts or tensions that may be present, and makes for shared experiences in the wins, losses and occasional transcending moments that carry forward over time.  Go Dodgers!

Thursday, October 19, 2017

Scary Alzheimer's



Halloween is approaching and so we thought we should do a blog about the thing that scares people most about growing older—Alzheimer’s disease and the other disorders that lead to dementia. 

So you’re in the doctor’s office for an annual physical and the doctor says three words, for example, ball, flag, tree, and asks you to remember them.   Or asks you to subtract 7 from 100 and then continuing subtracting 7s.  You know what’s going on.  You are being tested on the kinds of tests used to screen for dementia.  So are you feeling a little anxious about how you will do?  It is probably no surprise that anxiety is likely to make it harder for you to do those tasks.

A new study done by a French and American team of researchers shows that giving people instructions that increase their fears about how they will perform on a dementia screening test leads to poorer performance on the tests.  In the study, a sample of community living adults who were 75 years old were given two tests that are widely used by doctors and other health professionals to screen for dementia and for Mild Cognitive Impairment, the Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MoCA). 

If participants were told they were taking a test that older and young people performed differently on, then about half of them scored on the impaired range.  If they were told that older people and younger people did about the same, between 5 and 15 percent fell in the impaired range.  Before they were given the second test, the investigators gave new instructions to the people who had previously been told that they might do more poorly because they were older.  Now they were told that the second test was one that young and old did equally well on.  As a result, their performance improved.

The take home message is if you scare 75 year olds before giving them a test, up to one half will show some impairment.  But if you give them neutral instructions, the actual number that have impairment is between 5 and 15 percent, depending on the test.  This leaves a huge chunk of people who could be misdiagnosed.

When Judy was in private practice doing neuropsychological testing for dementia, she felt strongly that it was important to err on the side of under-diagnosis.  If she had any doubt in the testing, she felt that giving people reassurance would help them worry less, which could improve their everyday performance.  She would arrange for re-testing in a year, and told clients it could lead to three possible outcomes, two of which are good.  A person could get better or stay the same, which are both good outcomes indicating they do not have dementia.  If they declined, it was important to consider how much of a decline was shown before concluding it was dementia.  There can be a little bit of age-related decline that is not early dementia.  In other words, she believed it was unethical to conclude that someone had dementia without being 100% sure. 

From the beginning of our careers, we have seen people who were wrongly diagnosed as having some type of dementia.  Mild Cognitive Impairment is an even fuzzier concept.  Many health care professionals regard it as the first stage of Alzheimer’s but there is increasing evidence that as many as 53 percent of people who are given the diagnosis do not have dementia.  These false positive findings may be due to many factors, such as medications, transient health problems, or as this study showed, just the perceived threat that the test holds can lead to anxiety which leads to poor performance.

The Mild Cognitive Impairment category has become popular because of an emphasis on early detection of Alzheimer’s.  The argument goes that a treatment will only be effective early in the disease, before a lot of the damage to brain neurons occurs.  But efforts at early detection raise the risk of false positive diagnoses, which can cause considerable anxiety and potentially could lead to people trying treatments for a disorder they do not even have, and that are not without their own dangers.  Alzheimer’s is a scary and awful disease.  Efforts at detection need to be tempered by an awareness of the limits of current tools for diagnosis. 

Happy Halloween.

Reference:

Mazerolle, M., et al., (2017).  Negative aging stereotypes impair performance on brief cognitive tests used to screen for predementia.  Journals of Gerontology: Psychological Sciences and Social Sciences, 72, 932-936.  doi:10.1093/geronb/gbw083