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Passing Interest

It’s hardly news that America’s Internet and smartphone culture has transformed the way people live.

But not everyone knows they’re also changing the way people die — or, more specifically, how they plan for death and the often-difficult process of transferring key information, end-of-life wishes, and even treasured memories to their loved ones.

cakeTake Cake, for instance. This free online platform helps people determine and share their end-of-life wishes. Similar to the popular dating app Tinder, Cake outlines and organizes these wishes by presenting users with a number of questions on which they can swipe yes or no. Based on the answers, the app creates a profile divided into four categories — legacy, health, legal/financial, and funeral — each of them accompanied by action steps one could take to carry out those wishes.

“Each and every one of us should have a say in how we live our lives, from beginning to end (and even beyond),” the Boston-based Cake creators note. “Gift your loved ones with the information of what you would want, and how you want to be remembered.”

For many people, they note, thinking about the end of life isn’t a morbid activity, but can be a motivating factor to live life to the fullest. “It can put things in perspective and give you and your loved ones more peace of mind. It is a very considerate act to let your loved ones know what you would want. You can go at your own pace, and plan as much as feels right to you.”

Even folks with a will can benefit from such a service, the company notes, because many aspects of end-of-life planning — right down to the food one would want served at one’s funeral — are typically not be covered in that document.

“Additionally, medical preferences can be difficult to think through,” they go on. “Cake helps uncover your values so you can be clearer on your preferences, and so that your loved ones can be clear on them too.”

Plenty of Options

But Cake is far from the only player on this unique scene, which mixes some time-honored concepts with a decidedly 21st-century twist. Here are some of the others.

everplansEverplans, in some ways similar to Cake, is a digital vault for a person’s end-of-life plans, described as “a complete archive of everything your loved ones will need should something happen to you.” The app allows users to securely store wills, passwords, funeral wishes, and more in a shareable vault. Documents may include anything from wills, trusts, and insurance policies to bill-payment schedules, advance directives and do-not-rescuscitate orders, as well as final wishes and funeral preferences.

Users begin by taking a short assessment survey to see how much planning they’ve already done, how much else they need to do. Based on that information, the service, which costs $75 per year, creates a to-do checklist and helps prioritize that list. The user then assigns specific ‘deputies’ for the plan, so loved ones can find everything neatly in one place.

mydirectivesMore of an emergency-care tool than an strictly an end-of-life plan, MyDirectives allows people to speak for themselves — digitally. Users populate their ‘medical ID’ with date such as their health information and end-of-life plans. This allows doctors to have access to this information right from a patient’s iPhone lock screen.

The four basic parts to this free service are ‘My Decisions,’ which outlines care preferences, values, and treatment goals; ‘My Thoughts,’ which uses messages, video posts, music, and photos to help caregivers know more about the patient; ‘My Healthcare Agents,’ which outlines who represents the patient during a health crisis when he or she can’t communicate; and ‘My Circle,’ which keeps key contact information in one place.

principled-heartThe creator of Principled Heart, a certified financial planner, said his goal was to help answer a common question: where do we keep all our planning documents and information — and how will my loved ones know what to do? His site encourages people to keep only what is necessary, including passwords (or instructions on where to find them) for financial accounts, social media, and other accounts. Other features include instructions for pet care, key contacts, and space to upload up to 60 documents.

Three specified people are required to validate the account owner’s death, and then the site, which costs $45 a year for up to one gigabyte of storage, will provide access to all the information stored inside.

afterstepsAfterSteps, created by a Harvard Business School student, also requires the names of three verifiers, who will be notified in the event of the user’s death and will get access to all information stored on the site, which includes wills and other legal forms, passwords and instructions for digital accounts, funeral-arrangement wishes, and other data. It costs $60 a year or $299 for life.

Most services of this sort are recent developments, but a few have a longer history. DocuBank was created in 1993 as a registry to give members 24-hour access to their advance directives. More than 200,000 members have used the service ($55 per year) since then, and DocuBank has added new features, including an online vault called SAFE that provides a place for members to store files. The site’s latest ‘Digital Executor’ feature allows members to designate one person who will be able to access all of their online files once they’ve presented proof of the member’s death or permanent incapacity.

Celebrating Life After Death

Many end-of-life planning apps are about more than financial and funeral arrangements; however, crossing over into the realm of preserving history and sharing memories.

safebeyondFor example, SafeBeyond ($48 to $96 per year) defines itself as a ‘legacy-management service.’ As such, this app allows users to keep record of their life story in the form of meaningful digital content. SafeBeyond’s distribution capabilities then allow for the future delivery of this content in the form of personalized messages accessible by specific loved ones – almost like emotional life insurance through which one can be remembered.

“Everyone’s life story is unique and constantly affected by change,” the creators write. “Our platform provides an innovative online and mobile-app solution for the easy and secure management of your life story and your meaningful digital content, with enhanced distribution capabilities for the future delivery of personalized messages and digital assets. You decide when, where, and with whom your messages and other digital assets will be shared.”

The app allows people to record text, audio, and video messages throughout their life and store them in a heavily encrypted ‘digital vault.’ Then, SafeBeyond will send messages on behalf of its clients for up to 25 years after they die. Many users choose to schedule those messages on birthdays or on the anniversary of their passing. After the user dies, their recipients are e-mailed a notification telling them to download the app so that they can, one day, receive a message from the grave.

eterniamMeanwhile, Eterniam provides a free, secure online locker for one’s personal digital assets, including photos, videos, and other documents, and then releases them after the user’s death to whomever he or she specifies. Rather than focus on death, the app encourages users to ‘celebrate life,’ and to capture moments and upload them to the cloud.

Bcelebrated ($20 yer year, $100 for a lifetime membership) enables members to create a multi-media website that will become their autobiographical memorial site when the time comes. They may share their story in words, images, and audio; write password-protected private messages for loved ones; and essentially leave a permanent site where friends and family can celebrate a life.

Members create password-protected private pages for loved ones, record their last wishes, and assign a charity to receive donations on their behalf. The service also sends automated notification e-mails at the time of a member’s death and provides a list of numbers for those who need to be called.

Finally, on a different, slightly more downbeat note, Life Countdown is a free app that asks users to pick the date they think they’ll live to, then sends notifications at random intervals about how much time they theoretically have left. The app, its creators say, has a philosophical bent: “to cultivate the contemplation of death.”

Some might feel that’s a worthy-enough goal. For those who want to do more than contemplate, but instead do some real planning about what they’ll leave behind, today’s online culture offers plenty of options.

Business of Aging Sections

Aging in Place

Suzanne McElroy

Suzanne McElroy says it’s important to match a family with the right caregiver to ensure there’s a comfort level on both sides.

As the Baby Boom generation continues to advance into the golden years, the demand for home care continues to rise, as families embrace a model that keeps seniors stay in their homes while helping them with everyday needs. That means the need for qualified caregivers is rising, too — and it’s not always easy to find them.

Home care is a far cry from, say, plumbing, Suzanne McElroy says. Sure, both careers require specialized skills, but not a lot of plumbers are turned away because they just don’t … feel right.

“I’ve often tried to compare this to other industries, and you can’t,” said McElroy, owner of Home Instead Senior Care in Springfield. “A plumber can come in and fix your pipes, and you don’t have to worry about what they look like or smell like, or how they talk; they just come in and fix your pipes. But I’ve had caregivers rejected for silly things, like a tattoo in the wrong place, or things I’m not legally able to consider, like age, race, or religion.”

Paul Hillsburg, owner and president of Amada Senior Care in West Springfield — who left financial services for a career in this fast-growing field — has observed similar difficulties matching caregivers to families, starting with his own life.

“I saw the challenges we had with my mom in finding qualified caregivers,” he said, noting that she utilized home care in the early stages of her dementia. “My dad fired the first seven. I realized that was an important part of providing care in the home — the personalities need to match. So we take a personalized care approach.”

After all, McElroy said, she has to consider things from the family’s perspective, and why they need a certain comfort level with someone who will be spending lots of time in the home. “It’s not like fixing pipes and leaving; they’re going to be staying and sitting with your mom.”

SEE: List of Home Care Options

The problem, both she and Hillsburg, noted, is that the challenge of making those matches, plus the surge of Baby Boomers into their senior years — around 10,000 are turning 65 every day, on average — are ratcheting up the pressure on home-care agencies to find and retain talent.

“More and more people want to stay at home, and hospitals are actually suggesting home care during discharge,” Hillsburg said. “People want to age in place, to be at home, where their family can come and visit, and where they feel more comfortable.”

Home-care services run the gamut from companionship and household help to assistance with ambulation and medical needs, and the popularity of this option continues to grow, creating worries that demand will eventually outstrip the number of qualified caregivers. That means competition among agencies, which are bringing myriad tools to bear with the goal of helping seniors live as independently as possible.

The Right Choice?

McElroy, who has lectured many times on the topic of choosing a senior housing plan, outlined several considerations that families must discuss, including:

• Physical needs, including activities of daily living — from shopping, cleaning, cooking, and pet care to more intensive help with bathing, ambulating, and eating — and medical needs, which could arise from a sudden condition, such as a heart attack or stroke, or a more gradual condition that slowly needs more care, such as Alzheimer’s disease.

• Home maintenance. “If you’re living alone, your current home may become too difficult or too expensive to maintain,” she noted. “You may have health problems that make it hard to manage tasks such as housework and yard maintenance that you once took for granted.”

• Social and emotional needs. As people age, their social networks may change, with family and long-time friends no longer close by, and neighbors moving away or passing on. At the same time, they may no longer be able to drive and have no access to public transportation. The desire to be around a community of friends and take part in social activities may be paramount.

• Financial needs. “Modifying your home and long-term care can both be expensive, so balancing the care you need with where you want to live requires careful evaluation of your budget.”

The answers to these questions may very well point to assisted living as a better option than home care, but others may be able to age in place, accessing home-care services to better manage activities of daily living, while still enjoying the comfort and security of a residence they have lived in for years or decades.

Aging in place is a less effective senior-housing option once your mobility is limited. Being unable to leave your home frequently and socialize with others can lead to isolation, loneliness, and depression. So, even if you select to age in place today, it’s important to have a plan for the future when your needs may change and staying at home may no longer be the best option.”

“You may also be able to make home repairs or modifications to make your life easier and safer, such as installing a wheelchair ramp, bathtub railings, or emergency response system,” McElroy said.

Home care is a good option, then, for people who can access transportation; live in a safe neighborhood and in a home that can be modified to reflect changing physical needs; don’t have an overwhelming burden of home or yard maintenance; have physical or medical needs that don’t require a high or specialized level of care; and, perhaps most important, have a network of nearby family, friends, or neighbors.

“Aging in place is a less effective senior-housing option once your mobility is limited,” she added. “Being unable to leave your home frequently and socialize with others can lead to isolation, loneliness, and depression. So, even if you select to age in place today, it’s important to have a plan for the future when your needs may change and staying at home may no longer be the best option.”

Individuals and families who do choose home care, Hillsburg said, still have to overcome that initial reluctance to invite a stranger into their home.

“When I meet clients, I do my own personal assessment, trying to link their personalities with the personality of the caregiver,” he explained. “And when the caregiver goes to the family’s home for the first time, I meet them there and introduce them to the family, make sure there’s a comfort level there.”

Hillsburg said his company, part of a national network of Amada franchises, also performs extensive background screening — credit history, DMV records, criminal records, sex-offender registries — to ensure client safety, and also assists people trying to figure out how to pay for care, whether that’s a long-term care policy, veterans’ benefits, reverse mortgages, even life-insurance policies that can be sold back, swapping death benefits for current care.

Paul Hillsburg

Paul Hillsburg says the biggest challenge for home-care companies is finding and retaining quality caregivers in an increasingly competitive arena.

But to build a team of reliable caregivers at a time when the competition for talent is becoming fiercer by the month, a company has to make sure they’re paid well and happy in their jobs, he told BusinessWest.

“It’s a very, very competitive field. The biggest challenge going forward is going to be finding and retaining good, quality caregivers. That’s why we provide 20 hours of free training, or more, if they want it, to all our caregivers, and we pay them while they’re in that training,” he explained. “They want to be treated like a person and respected.”

Cost is still a major consideration for families, McElroy said, especially when agencies have to pay their caregivers competitively. While lower-income services are available through Medicaid and MassHealth, home care still isn’t within reach of everyone who needs it. “That’s only going to change in importance when enough people feel this pain, or the right people feel this pain.”

High-tech, High-touch

At the same time, Hillsburg said, home care continues to absorb technological advances that make it easier for families and companies to assess results, from an online portal Amada offers called Transparent — which allows families to see which duties a caregiver has performed — to a GPS system that lets the company know whether caregivers show up at the right place and time.

Meanwhile, the company’s Discharge Admissions Reduction Team (DART) works with care managers to negotiate transitions between hospital and home care with the goal of reducing hospital readmissions.

“The need for care is going to continue to increase for the next 30 years before we hit the end of the Baby Boom generation,” Hillsburg said by way of explaining the ways companies are honing their services to meet the needs of this population.

Still, at the end of the day, McElroy said, families are most concerned with whether the caregiver increased their loved one’s quality of life. She recalled one client who requested someone versed in quilting, to help her thread needles and otherwise allow her to continue enjoying her favorite pastime.

“That’s the heart of what we’re doing. Yes, we’re helping them out of bed and into the shower, but if we can help someone live the live they want, that’s what’s driving the spirit of our business,” she explained. “It’s hospitality; it’s customer service. You have to love what you’re doing. You have to love the mission and love the work.”

After all, “whenever I have someone raving about a caregiver, it’s not because they came in for a few hours and got the job done; it’s because they made a difference in someone’s life,” McElroy said. “They can be doing the grossest thing ever, but when they leave, if the person takes their hand and says, ‘I don’t know what I would do without you,’ they’re flying. They can’t wait to go back.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections

A Matter of Time

Dr. Rajiv Padmanabhan

Dr. Rajiv Padmanabhan says the initial 911 call triggers a chain of events at the hospital that ensures everyone is in place to treat a stroke quickly when the patient arrives.

Everyone knows women who are fiercely independent and used to doing everything for themselves. Getting to the hospital after a stroke — or, more likely, getting a friend or loved one there — shouldn’t fall into that category.

“We stress to stroke patients that we want them to come to the hospital quickly,” said Patti Henault, coordinator of Stroke Programs at Mercy Medical Center. “Every minute someone is having a large stroke is a minute that is wasted, and a little part of your brain is going to be damaged. Basically, the quicker you get treatment, the better the outcome usually is. But to arrive as fast as possible, you should call EMS. People think an ambulance takes longer, but the thing is, EMS lets us know they’re coming, so we can get everything in place. That helps a lot.”

Once the patient calls 911, she explained, the ambulance crew is in contact with the hospital, so doctors and CT-scan technicians are in place the moment of arrival. “The first diagnostic test for stroke is do a CT scan, so we know what’s going on inside the brain,” Henault said. “It’s a quick test, but the faster we can do it, the faster we can know whether it’s something we can treat.”

Dr. Rajiv Padmanabhan, a neurologist with Baystate Health, said the system has an algorithm — a chain of command, if you will — for stroke response, and it begins with the EMS team.

“When they call into the hospital, we are on standby, with the CT scan and neurology team and the emergency room; we’re all aware that a patient with a stroke is coming on the ambulance,” he told BusinessWest. “The 911 call triggers the whole thing. They go straight to the CT scan, and we also look at pictures of the arteries.

“The most important lesson is to get them treated fast,” he went on. “Every minute, 1.9 million neurons are lost in the brain. The sooner we treat them, the better chance we have of getting blood supplied back to the brain, which is what we aim for. Once the patient calls 911, the likelihood of a good outcome increases. It sets up a chain of command, which notifies techs, the lab, pharmacy, and the ER. It triggers a chain of events that leads to faster delivery of care. 911 makes a difference.”

According to the American Stroke Assoc., stroke is the third-leading cause of death for women and the fifth-leading cause of death for men; each year, 55,000 more women have a stroke than men. And because women live longer on average than men, strokes often have a more negative impact on their lives. In fact, women are more likely than men to live alone when they have a stroke; require the services of a long-term healthcare facility after a stroke; and have a worse recovery overall.

But with proper management of risk factors, and a quick response when an event occurs, women, as well as men, have a better chance of decreasing mortality rates from stroke and boosting quality of life.

On the Clock

Once a stroke patient arrives at Mercy, Henault said, a consultation is conducted with a neurologist from Massachusetts General Hospital in Boston through that institution’s stroke telemedicine program. “They can see the patient, give directions, answer patient questions, they can even zoom close up on eyes and check the pupils. It’s pretty amazing. They can give us advice on how to treat the patient.”

Patti Henault

Patti Henault says many risk factors for stroke — like high blood pressure, obesity, and smoking — are manageable with lifestyle choices.

Mercy began using the Mass General service in January 2016 because they are always ready to consult. “The neurologists in our area are often with patients, and it’s difficult to stop what they’re doing. We decided we’d get quicker service with telemedicine. And it really has made an impact.”

About 85% of all strokes are ischemic, caused by a clot, while the rest are hemorrhagic strokes, which are treated differently. In the case of an ischemic stroke, the first line line of defense is the blood-thinning agent tPA (tissue plasminogen activator), known colloquially as a ‘clot buster.’

“If there is a problem like a clot blocking an artery or arteries are very narrowed because of artherosclerosis, we might be able to resume blood flow to the brain,” Henault said. “The idea is, if we can resume blood flow to the brain, the brain cells stop dying because they’re getting the nutrients and oxygen they need.”

For patients that require a more dramatic intervention than a clot buster, a cutting-edge device in use at Baystate known as the ‘stentriever’ can actually be inserted into the artery to remove the clot.

“We’ve incorporated that as part of the protocol,” Padmanabhan said. “We want to make sure we have the right tools, state-of-the-art tools, to respond 24/7/365 and get all patients to the right treatment immediately.”

He added that doctors are waiting on trials and studies examining whether such interventions may be employed more than seven hours after a stroke, which is considered the current limit. (Clot busters like tPA are typically administered no more than four and a half hours out). “Expanding the window might capture more big strokes before disability and death. We won’t get them all, but we can decrease mortality.”

The best medicine, of course, is not to have a stroke at all, and fortunately, most risk factors are lifestyle-related and can be managed in most people.

“High blood pressure is huge one,” Henault said. “A lot of people think high blood pressure is kind of harmless, but it’s insidious because it does damage to blood vessels every day, and if you have high blood pressure, it’s constantly wearing down the side of the blood vessel, and one crack can develop a blood clot because the body is trying to fix it.”

Other risk factors, she went on, include being overweight, lack of physical activity, and behaviors like smoking, excessive drinking, and drug abuse. “Our younger stroke victims, especially, tend to have some high-risk behavior such as that.”

Some stroke risks require medical intervention, such as atrial fibrillation, or irregular heartbeat, which increases an individual’s chance of developing blood clots. Many with this condition take blood thinners on a regular basis.

“The most important risk factors are hypertension, diabetes, high cholesterol, and obviously smoking,” Padmanabhan said. “Quitting smoking and controlling sugars are important for treating blood pressure. Sleep apnea also has a correlation, so if you feel foggy and tired all the time, check it out and make sure it’s treated. You don’t have to be obese or have a metabolic syndrome to have sleep apnea.”

Although it sounds simple, he added, regular doctor visits can go a long way toward preventing strokes, as will following the American Heart Assoc. guidelines to engage in 20 minutes of moderate exercise five times a week. “The important thing is knowing your numbers. You won’t get to your goals in a day.”

For recovering stroke patients without these risk factors, Padmanabhan said, Baystate’s stroke clinics in Springfield and Greenfield conduct diagnostic cardiac testing to try to determine a cause. But there’s no one way to rehab from a stroke, Henault added.

“No two people are the same. Every section of the brain controls different things, so everyone’s treatment after a stroke is different. Younger brains tend to recover more quickly.”

Different for Women

Each year, according to the American Stroke Assoc., stroke kills twice as many women as breast cancer. But the public tends to be less knowledgeable about the risk factors and don’t perceive themselves at risk for stroke.

In addition to the general risk factors like family history, high blood pressure, high cholesterol, diabetes, smoking, lack of exercise, and being overweight, women face some unique risk factors, including:

• Taking birth control pills. The greatest concern about using oral contraceptives is for women with additional risk factors, such as age, cigarette smoking, high blood pressure, or diabetes;

• Being pregnant. Stroke risk increases during a normal pregnancy due to natural changes in the body such as increased blood pressure and stress on the heart;

• Using hormone-replacement therapy, a combined hormone therapy of progestin and estrogen, to relieve menopausal symptoms; and

• Suffering from migraine headaches with aura. Migraines can increase a woman’s stroke risk two and a half times, and most people in the U.S. who suffer migraines are women.

Women may also report symptoms that are different from common stroke symptoms. These can include loss of consciousness or fainting; general weakness; difficulty or shortness of breath; confusion, unresponsiveness, or disorientation; sudden behavioral change; agitation; hallucinations; nausea or vomiting; pain; seizures; and hiccups. Because these are not typically recognized as stroke symptoms, treatment is often delayed.

Henault said men and women should at least know the FAST symptoms. That’s an acronym stroke-care professionals use to help people recognize the signs of a stroke. The letters stand for facial drooping, arm weakness, speech difficulties, and time — which is of the essence, so call 911 immediately.

“It sounds silly,” she said, “but little kids understand that, and sometimes they end up calling 911.”

It could be the most critical call they ever make, because it launches a chain of events at the hospital designed to save lives — and, more often than ever, does just that.

Joseph Bednar can be reached at [email protected]

Business of Aging Sections

Sight Restoration

Dr. John Papale says most patients who undergo cataract-removal surgery see a more than 95% restoration of vision.

Dr. John Papale says most patients who undergo cataract-removal surgery see a more than 95% restoration of vision.

As the population ages, eye problems will become an increasingly large healthcare issue for society. Fortunately, modern science and new surgical techniques are bringing improved vision — and better quality of life — to those suffering from a number of common ailments.

Several months ago during a routine eye exam, Louise Pugliano was told that she had cataracts in both eyes. The 84-year-old doesn’t drive at night and had no symptoms, but had worn glasses or contact lenses for more than 20 years, and agreed to have cataract-removal surgery.

The first procedure took place Jan. 8, and the second was done Jan. 23, and they were not only painless, but the Springfield woman was thrilled to find she no longer needs prescription eyewear.

“I’m so glad I did this; I had a great experience and wonderful results: I don’t need glasses anymore and can read the small print in the newspaper,” Pugliano said, adding that she had complete faith in her surgeon, Dr. John Papale of Papale Eye Center in Springfield.

Her diagnosed condition, treatment, and response to it are all typical of what’s happening within the broad realm of eye care today — as the population ages, more people are being diagnosed with problems, but modern science has created solutions, many of which are truly life-altering.

Papale told BusinessWest that cataract removal is the most commonly performed surgery in the U.S., and more than 3 million people have the procedure done every year. The 20-minute outpatient operation corrects vision and eliminates troublesome symptoms that affect many seniors, such as seeing halos or being bothered by the glare of oncoming headlights when driving at night.

“Most people have more than a 95% restoration of vision, assuming there are no other problems such as glaucoma and macular degeneration,” Papale said, as he spoke about conditions that affect aging eyes.

Indeed, they are common. The Mayo Clinic reports that about half of all 65-year-old Americans have some degree of cataract formation, and more than 30 million Americans are expected to develop them by 2020. In addition, more than 6.5 million Americans age 65 and older have a severe visual impairment, and rates of severe vision loss are expected to double by 2030.

Dr. Camille Guzek-Latka, an optometrist at Chicopee Eyecare, P.C., says many people use over-the-counter glasses to avoid getting an eye exam. “But the exam is important; we not only evaluate the need for glasses, we look for evidence of eye disease because, as people age, their risk of developing a problem increases.”

Annual eye exams are critical for people over the age of 60 because eye disease can cause irreversible blindness and there may be no symptoms until it reaches an advanced stage.

Dr. Andrew Jusko says an eye exam is needed to detect glaucoma, as there are no symptoms in the early or middle stages.

Dr. Andrew Jusko says an eye exam is needed to detect glaucoma, as there are no symptoms in the early or middle stages.

Although some people don’t have vision coverage on their insurance plan, Eye Care America has provided free exams to almost 2 million eligible seniors (visit www.aao.org), and health-insurance plans cover the cost if a minor medical problem is uncovered, which usually happens as people get older.

“It’s important to protect against damaging eye diseases; people are living longer today and want to maintain full visual functionality through the end of their lives,” said surgeon Dr. Andrew Jusko of Eyesight and Surgery Associates in Springfield and East Longmeadow.

Papale agrees. “The eye is our most important sense: 25% of all input to the brain comes from the eye and nerve endings,” he noted.

For this issue and its focus on the business of aging, BusinessWest examines problems that affect aging eyes and what can be done to prevent and correct them.

Cause, Effect, and Treatment

The lens of the eye consists of a flexible jelly that begins to stiffen as people enter their 30s and 40s. The condition is called presbyopia, and most people need reading glasses to compensate for the fact that their eyes can no longer shift focus easily.

“Many people in their 40s and 50s get by with over-the-counter reading glasses, but by the time they reach their 50s or 60s they usually don’t work well,” Jusko said, adding that early stages of other diseases such as diabetes or hypertension can be seen in the eyes during an exam.

Cataracts cause the lens to change from crystal clear to cloudy, and typically develop as people age. They don’t harm the eye but do affect vision, and surgery to correct the problem involves replacing the aging lens with an artificial one.

In the past, eye drops were always needed for a few weeks following the procedure, but Guzek-Latka said a newer approach is often used today called ‘dropless cataract surgery,’ which occurs when the surgeon injects a combination of antibiotics and steroids into the eye at the time of the procedure to reduce the need for drops after it.

“The surgery is safe and wonderful; it can restore sight, reduce the risk of falling, and people are thrilled with the results,” she noted, adding that, although cataracts are related to aging, prolonged use of steroids for conditions such as asthma can cause them to develop earlier.

Cataracts are a change that occurs as the eye ages, but glaucoma is an age-related disease that causes blindness as the peripheral or side vision is lost.

“It’s called the silent thief of sight because the vision loss occurs slowly and painlessly,” Guzek-Latka said, adding that the condition is linked to a buildup of pressure inside the eye, but it can take many years for the vision loss to occur.

The disease can start in the 40s, but risk increases with age. “People cannot tell if the pressure inside their eye is normal, so they can be going blind and not know it,” Papale told BusinessWest, noting that, since glaucoma frequently only affects one eye, the other eye compensates for it so the person doesn’t realize what is happening.

As a result, it’s critical to catch the disease before irreversible damage is done. “An eye exam will show whether the pressure is normal and if the optic nerves appear abnormal,” Jusko said.

Some forms of glaucoma can be cured, and treatment ranges from surgical procedures to prescription eye drops that control pressure inside the eye.

Jusko often uses eye stents during surgery, which are small devices implanted in the drainage area of the eye to help reduce the need for future medication.

“The average age for glaucoma is the 70s, which is about the same age that people need cataract surgery,” he said, noting that stents can also be used during that procedure.

Age-related macular degeneration, or AMD, is one of the most serious eye diseases and the leading cause of blindness in seniors. “The macula is the part of the retina that gives you the sharp vision you need to read, drive, and recognize faces,” Papale said.

More than 2 million Americans are afflicted with some form of the disease, and that number is expected to more than double to 5.4 million by 2050 due to the aging population.

“It’s the leading cause of irreversible vision loss in people age 50 and older, and treatment for it is limited,” Guzek-Latka said.

“There are usually no symptoms in the early stages, but the disease can be seen when the pupil is dilated during an eye exam,” she continued, adding that, as the disease progresses, it causes distortion in the central vision. “People can still see things on the side, but they can’t read, and faces often appear as dark gray areas. Most people think blindness means total blackness, but it’s very rare not to be able to see any light.”

The cause of AMD is unknown, but it’s important for people to be aware of risk factors. Smoking doubles the risk of macular degeneration, it tends to run in families, women are more likely to develop it than men, and it is more common among Caucasians than African-Americans, Hispanics, and other races.

“People might be able to reduce their risk of macular degeneration or slow the progression by making healthy choices such as regular exercise, maintaining normal blood pressure, quitting smoking, and eating a healthy diet rich in green, leafy vegetables and fish,” Guzek-Latka said.

The disease is divided into two categories — wet macular degeneration and dry macular degeneration. Although there are no symptoms associated with early dry macular degeneration, the vision becomes distorted over time, and once function is lost, it cannot be restored.

However, further damage may be prevented with special vitamins formulated for the eye. “But we don’t recommend taking them unless the person has been diagnosed with macular degeneration,” Jusko said, noting that studies show no definitive or preventive benefits for people without the disease.

Wet macular degeneration is caused by the growth of abnormal blood vessels under the macula that are fragile and prone to bleeding.

“The bleeding is not visible because the macula is in the back of the eye,” Papale said, adding that the dry form of the disease can progress to the wet type.

Treatment includes injections of medicine that block the growth of abnormal blood vessels and can lead to some improvement.

“It won’t cure the disease, but it’s definitely an advance; 10 years ago, there was less hope for people with wet macular degeneration then there is today,” Guzek-Latka said.

She added that FDA approval was granted for an implantable device in 2010 that is used at the end stages of the disease. It’s the size of a pea and magnifies images onto the retina.

“But it’s only used as a last resort. It will not restore vision, but might allow someone to identify faces, even if they are not clear,” she said.

Diabetes is another disease that affects the eyes. According to the National Eye Institute, 40% of Americans over age 40 have some degree of diabetic retinopathy, and one of every 12 people with diabetes in this age group has advanced, vision-threatening retinopathy.

That’s a condition that results when small blood vessels in the retina leak blood or other fluids that cause progressive damage to the retina, which is the light-sensitive lining at the back of the eye.

“Once someone is diagnosed with diabetes, they need yearly eye exams to detect it,” Jusko said.

Treatment ranges from the use of lasers to injections and surgical procedures, and primary-care physicians usually work closely with the person to ensure their blood-sugar levels and blood pressure are under control.

Hope for the Future

Dry eye is another condition that can affect people of any age, but is more prevalent in elders and post-menopausal women. It results from inadequate tear production and causes burning, stinging, itching, or the feeling that sand is in the eyes.

It can be alleviated with over-the-counter lubricating drops, fish-oil supplements, and vitamin C. But dry eye that is moderate or severe can cause damage, so people whose symptoms aren’t helped with over-the-counter remedies should see their eye doctor.

There is no doubt that eyesight is affected as people age, but there are things everyone can do to help to prevent disease. Eyes need good blood circulation and oxygen intake, and since both are stimulated by regular exercise, it ranks high on the list.

People should also do their best to maintain normal blood pressure and cholesterol levels, and wear sunglasses that block ultraviolet light.

But getting an annual eye exam is the most important measure anyone can take to preserve vision.

“Eyesight is our most important sense,” said Guzek-Latka. “We rely on it for so many things, and having good vision is a driving factor in people’s well-being as they age.”

Business of Aging Sections

The Write Stuff

By Gina Barry, Esq.

Gina Barry

By Gina M. Barry, Esq.

It should come as no surprise that the general population of the U.S. is aging. According to the Administration for Community Living, which was created by the U.S. Department of Health and Human Services, people who were age 65 or older represented 14.5% of the population in 2014, and that number is expected to grow to 21.7% of the population by 2040.

When aging, most people would prefer to have a plan in place to ensure that their needs and goals will be met, even if they are incapacitated or pass away. While many people believe they do not have enough money to need an estate plan, the need for an estate plan is not solely related to the amount of one’s wealth.

As explained below, a basic estate plan is comprised of four legal documents and is quite simple to establish.

Last Will and Testament

A will directs the disposition of the probate estate. The probate estate consists of assets held in the decedent’s name alone that do not have a beneficiary designated. When a person passes away without a will, their estate will be distributed as directed by the Commonwealth’s intestacy law, which may not be as they would have desired.

A common misconception is that a will is not needed if every asset is jointly owned or has a designated beneficiary. Of course, there must be a surviving joint owner for this plan to work. If both owners pass away simultaneously in a common accident, the estate will need to be probated, as there will be no surviving joint owner.

A will is also necessary in order to designate a personal representative, who will carry out the estate. The personal representative will gather the probate assets, pay valid debts, and make distribution of the estate to the beneficiaries as set forth in the will. Further, if the decedent leaves behind minor children, a guardian can be designated in the will to take custody of these children.

Likewise, a trust can be established in a will that would provide ongoing protection for minor children — or possibly for other beneficiaries who should not receive their inheritance outright, usually due to spendthrift concerns. When there is no will in place, the power and ability to make these designations and to direct the disposition of property is forfeited.

Healthcare Proxy

A healthcare proxy is a document that designates a healthcare agent, who would make healthcare decisions in the event of incapacity of the principal (person signing the proxy). The healthcare agent would step into the shoes of the principal and make decisions as they would if they were able. For example, they may decide whether a certain medication should be taken, whether a certain medical procedure should be done, or whether there should be an admission or discharge from a medical facility.


While many people believe they do not have enough money to need an estate plan, the need for an estate plan is not solely related to the amount of one’s wealth.”


‘Living will’ language is normally included within the healthcare proxy. The living-will language addresses end-of-life decisions and generally sets forth that the principal does not want extraordinary medical procedures used to keep them alive when there is no likelihood of recovery. This can be a difficult decision to carry out; therefore, care should be taken to name someone who would be able to honor that decision. Individuals who have an advanced illness may choose to establish medical orders for life-sustaining treatment (MOLST) in addition to a healthcare proxy.

A MOLST is a medical order form completed by a patient and their physician that relays instructions about a patient’s care, including stating which treatment should be given or otherwise withheld. A MOLST would eliminate the need for living-will language in a proxy, but the best practice would be to reference it in the proxy.

Durable Power of Attorney

A durable power of attorney is a document that designates someone to make financial decisions. This document is usually in full force and effect when it is signed, but it is expected that it will not be used unless you are unable to handle your own financial affairs. It is also possible to grant a springing power that does not take effect until incapacity arises.

Rehabilitation Facilities in Western Mass.

The power of attorney is a very powerful document that is as broad as the powers granted within it. It gives authority to the designated person to handle all financial decisions, not just pay bills. In most cases, the person named will be authorized to handle real estate, life insurance, retirement accounts, other investment accounts, bank accounts, and any other matters involving money.  As such, the person chosen to serve in this capacity should be someone with financial savvy who can be trusted without reservation.

Homestead Declaration

The homestead declaration, once properly recorded in the Registry of Deeds, declares a principal residence to be a homestead. The homestead declaration protects the equity in the primary residence up to $500,000 from attachment, seizure, execution on judgment, levy, or sale for the payment of debts.

In some cases, such as advanced age or disability, the equity protection can be up to $1 million. If a homestead declaration is not recorded, there is an automatic $125,000 of equity protection.  In addition to some other specific exceptions, a homestead declaration will not protect the real estate from nursing-home costs or tax liens.


With these four documents, most people can help their family members or trusted companions avoid expensive and painful legal hassles related to their ongoing care and their estate.

Individuals with more complicated estates may require different or additional documents to fully protect their interests and their beneficiaries, but for the majority of people, an estate plan is only four documents away.

Gina M. Barry is a partner with the law firm Bacon Wilson, P.C. She is a member of the National Assoc. of Elder Law Attorneys, the Estate Planning Council, and the Western Mass. Elder Care Professionals Assoc. She concentrates her practice in the areas of estate and asset protection planning, probate administration and litigation, guardianships, conservatorships, and residential real estate; (413) 781-0560; [email protected]

Business of Aging Sections

A Transformation in Care

The living room at the Sosin Center for Rehabilitation

The living room at the Sosin Center for Rehabilitation, like other areas of the facility, are meant to
evoke a home-like feel for residents preparing to return to their own homes.

When JGS Lifecare launched the strategic plan five years ago that would become Project Transformation, the goal was to, well, transform the organization’s entire range of senior services to reflect 21st-century ideas about delivering care in a resident-centric way. The Sosin Center for Rehabilitation, the highlight of the project’s first phase, is a good example, employing the burgeoning Green House philosophy, a model aimed at making residents feel at home while achieving the independence they need to return to their own homes.

The hallways in the Sosin Center for Rehabilitation are wide, allowing for freedom of movement for multiple individuals going about the business of regaining their independence.

The bedrooms, as BusinessWest observed on a recent tour, are simple but elegant, with mounted flat-screen TVs and adorned with paintings created by local artists. The bathrooms are large, well-appointed, and completely accessible to people with ambulatory challenges, and the spacious common living room is bathed in natural light.

Martin Baicker

Martin Baicker says the Green House model has been proven to improve rehab outcomes and reduce rehospitalization rates.

“When we show people the Sosin Center, it speaks for itself,” said Susan Halpern, vice president of Philanthropy for JGS Lifecare, which opened the Sosin Center to short-term residents this month. “It’s the kind of environment where you’d want your loved ones to be cared for.”

The facility is named after George Sosin, a JGS volunteer, family member, former resident, and supporter who left $3 million dollars to JGS Lifecare in support of the center, the largest contribution received in JGS’s 104-year history. It contains two households, each designed to accommodate 12 short-stay residents. All 24 rooms are private, with full baths, and each home has a shared living room, dining room, den, kitchen, and porch, which provides seasonal access to the outdoors.

JGS unveiled the Sosin Center and the neighboring Michael’s Café — which connects the short-term rehab facility with the Leavitt Family Jewish Home, the organization’s nursing home — as part of phase 1 of Project Transformation, a multi-pronged endeavor to, well, transform JGS’ many senior-care elements into facilities that truly reflect 21-st century healthcare.

Notably, JGS Lifecare partnered with the Green House Project to implement a small-house model of care at the Sosin Center that is slowly becoming recognized throughout the industry for its success in reducing medication use and rehospitalizations, while affording greater socialization and interaction with caregivers.

Martin Baicker, president and CEO of JGS Lifecare, noted that more than 64% of all short-stay residents at JGS are successfully discharged to the community, which is more than 10% above the national average, but he expects the percentage to rise further at the Sosin Center.

The Green House model extends well beyond aesthetics, Baicker said, encompassing a three-pronged philosophy — real home, meaningful life, and empowered staff.

The first element is an effort to make short-term residents feel at home, not on some institutionalized schedule. “You wake when you want, go to sleep when you want — and it also looks like your home, architecturally,” he said.

Meaningful life means giving people choices in their day, and the small number of units allows residents to build strong relationships with the staff, he went on. “They feel a real sense of engagement.”

As for empowered staff, this might be the most important element of all, Baicker noted. Typically, he noted, an organizational chart extends from the top down, but here, it’s a series of concentric circles with the resident at the center, and the certified nursing assistants representing the second circle. “They provide personal care, cooking, laundry, light housekeeping, activities — and this is given by the same person spending an awful lot of time with the resident, getting to know them.”

Susan Kline and Stephen Krevalin

Susan Kline and Stephen Krevalin are co-chairing the $11 million capital campaign for Project Transformation.

The CNAs are supported by nurses; physical, speech, and occupational therapists; and perhaps a doctor, but still essentially make the day-to-day decisions about how the house is run, he explained. “That is totally, radically different than running a traditional nursing home.”

Person-centered Care

Of course, the Sosin Center isn’t a nursing home, which is why Halpern is happy that short-term rehab residents at JGS are no longer sharing space at Leavitt. “It’s not beneficial for someone to come in for rehabilitation and cohabitate with people in long-term care. They’re here short-term, getting ready to go home.”

Baicker agreed. “People in short-term rehab don’t want to feel like they’re in a nursing home.”

The Green House philosophy represents a stark change in the way the healthcare industry traditionally frames short-term rehab, Halpern added. “It’s person-centered care. You empower the residents to make decisions about how to model their daily lives and routines — when they get up, what food they eat. They have more say in their actual caregiving.”

Baicker said the outcomes of the Green House model have been impressive at other facilities that utilize it. Patients tend to need less medication, eat more food — because the scents of meals being prepared where they live activates their appetite — and engage in life in a more dynamic way, since they’re constantly engaged with the staff. “All those things combine to improve outcomes.”

Much of the rehabilitation incorporates activities residents will conduct once they’re back at home, from reaching shelves and preparing food to washing and bathing, said Susan Kline, who is co-chairing the $11 million capital campaign for Project Transformation with Stephen Krevalin. Both are longtime volunteers with the JGS Lifecare organization and former chairs of its board of directors.

Most Sosin residents will come from hospitals, but some from other settings, and while a small number may wind up in nursing homes, that’s rare; the idea is to prepare individuals to return to their homes and independence.

“The outcomes have proven to be much more successful in this setting than what occurs in other areas,” Kline added.

When Baicker came on board in 2012, JGS was already busy strategizing for the series of changes that would eventually become Project Transformation, including planned improvements to short-term rehabilitation and assisted living, as well as a revamp of the adult day health program to better serve a growing population of seniors in the early stages of dementia.

JGS Lifecare building committee members Frank Colaccino and Jeff Grodsky

JGS Lifecare building committee members Frank Colaccino and Jeff Grodsky unveil the Sosin Center for Rehabilitation at the facility’s recent ribbon-cutting ceremony.

But he was one of the first in the organization to promote the Green House model, and when the board responded positively, team members started paying visits to other facilities that had incorporated it, from Mary’s Meadow in Holyoke to the Leonard Florence Center for Living in Chelsea.

“The board did their due diligence and decided this is the way we’re going to move,” he said. “And, ultimately, we want to expand this model to the long-term portion of the nursing home.” Indeed phase 2 of Project Transformation will turn to modernizing two 40-bed wings of the Leavitt Family Jewish Home in the Green House model.

Construction of the 24,000-square-foot Sosin Center and the adjoining kosher café began in June 2015, and both were dedicated at a ceremony last month shortly before their official opening.

The café is dedicated to the memory of the late Michael Frankel, who was an outspoken advocate for Project Transformation, Halpern said. “Naming the café in his honor is a permanent tribute not only to Frankel’s extraordinary commitment to the care of our elders at the highest standards, but also his vision for JGS Lifecare for generations to come.”

Krevalin hopes the café serves as a “beacon for the community,” noting that it connects the nursing home and the Sosin Center and is not only an ideal meal spot for residents, families, and staff, but for the public as well. “We’re hoping the community supports it.”

Ahead of the Curve

Project Transformation is far from the first time JGS leadership has moved away from traditional, stale facility design, Halpern said. As far back as the 1990s, the organization was renovating the nursing home and designing the Ruth’s House assisted-living facility to be more homelike and less institutional. “It’s all about making people feel comfortable in the environment where they’re living. The nursing home was built at a time when nursing homes were like hospitals, with nurses’ stations.”

Twenty years ago, a shift to a more home-like setting was still an innovative idea in healthcare, Baicker said. “You can’t underestimate the forward thinking of the leaders of this organization, making the common areas and dining areas less institutional. This [Project Transformation] is the continued evolution of that.”

“And believe me,” Kline added, “we’re already thinking about what’s next.”

Ruth’s House underwent some improvements as part of phase 1 as well, and phase 2, in addition to modernizing the nursing home according to the Green House model, will relocate and expand Wernick Adult Day Health Care to include a specialized Alzheimer’s program.

All this takes money — both phases were initially budgeted at $20 million but could eventually approach $23 million, Krevalin said — and more than 150 supporters have already contributed some $8.5 million to the capital campaign, which had an initial goal of $9 million but will be extended to $11 million.

“The initial response is heartening. It shows that many donors already understand the impact that our new facilities will have on the quality of life of our elders and others we serve,” Krevalin said. “Once people see Project Transformation, they will understand its impact, and they will want to be part of it.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections

Finders, Keepers

pileofjunkhoardingartWhen Bec Belofsky married Lee Shuer, she had no idea he had hoarding disorder.

When they met, he was living in an apartment with roommates, and she didn’t know most of the items in it, which included a ‘museum room’ filled with a seemingly endless number of things, belonged to him.

But within a short period of time, every surface in the married couple’s apartment was covered. In fact, although they could barely get through the apartment — and she had bruises from bumping into things — he continued to bring home ‘treasures’ on a daily basis. “I had a feeling of dread every time I heard the sound of his key in the lock,” she recalled.

Shuer told BusinessWest he also had a storage unit that was full and a collectibles booth in South Deerfield, but never sold much.  “I couldn’t let go of anything, so I had everything priced for more than it was worth,” he said.

Anyone has who watched TV shows depicting people who hoard might think there was little hope for Shuer or the marriage, but today much of the couple’s Easthampton home is immaculate, he has been in recovery for 11 years, and they have made it their mission to help other people with what they refer to as “excessive finding and keeping,” because the word ‘hoarder’ leads to feelings of shame and guilt.

They have appeared on many national and international TV and radio shows, including CBS Sunday Morning and Voice of America, and travel the world educating therapists, government officials, relatives of people who hoard, as well as hoarders themselves about what it takes to successfully overcome the disorder.

They want the public to know that television shows that portray interventions with people who hoard are extreme and not representative of the majority of people with the problem. In addition, tactics that include forcing the person to make quick decisions about untold numbers of items, accompanied by threats from family members, can be devastating and lead to a return of the behavior after their space is free of clutter.

“There are kinder, gentler, more effective approaches to the problem,” Shuer said. “Telling someone to stop collecting things is like putting a warning on cigarettes. You have to have the motivation to stop, but once it becomes internalized, people find the strength of purpose they need.”


Lee Shuer

Top: before Lee Shuer overcame hoarding disorder, his home office was unusable. At left: today, his home office is well-organized and contains only items that are truly important to him.

He has worked with individuals, groups, and institutions ranging from Stanford University and Smith College to the Institute for Challenging Disorganization through the couple’s business, Mutual Support Consulting, and has created a program called WRAP for Reducing Clutter, which is a wellness and recovery plan.

Shuer also works with researcher Randy Frost, who co-authored the book Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding, to create The Facilitator’s Manual for the Buried in Treasures Workshop, as well as another workbook designed to help people with the problem.

Frost says the reason it is so difficult for people with hoarding disorder to relinquish possessions is that everything they save has real significance to them. In some cases, such as a journalist who collects newspapers, the collection is a concrete embodiment of their professional identification.

“So getting rid of them makes the person feel as if they are losing that piece of themselves,” said Frost, professor of Psychology at Smith College. “We don’t really know what the underlying cause is, although it is clearly an attachment issue, and there is some indication it is related to early life experiences.”

Jane Laskey, a psychotherapist from Holyoke Medical Center’s Behavioral Health Outpatient Center, has had clients with hoarding disorder, and each one of their situations has been unique. “In many cases, hoarding is a symptom; it’s something people do to protect themselves from feelings that are very scary or painful, including sadness, anger, or hopelessness that often originated in childhood,” she explained.

For this issue’s focus on health, BusinessWest explores the type of thinking connected with hoarding and offers advice from these experts to help people with an overabundance of possessions regain control of their lives.

Making Progress

Shuer’s love for tangible items began when he was about 4 years old and began asking neighbors if they had anything old they didn’t need. His parents allowed him to keep many of the things he was given, including old tools he really liked.

“I was socially awkward as I was growing up, and these things gave me comfort and something to talk about with other people,” he said, adding that, although he had a wonderful family, he often felt lonely because he was a social outcast at school. “I was looking for myself in the stuff I collected.”

For example, he’d always wanted to learn to play a musical instrument, and by the time he was married, he had collected far too many of them.

Today, Shuer tells people who hoard that “letting go doesn’t mean giving up a dream. You can come back to it, but you need to keep your eyes on the real prize.”

His own recovery began 11 years ago when Belofsky-Shuer heard of a study on hoarding that was being conducted by Dr. David Tolin, co-author of Buried in Treasures.

“We have developed treatments for the disorder that work fairly well, but they don’t work for everyone,” Frost said, noting that research continues to help people with hoarding disorder.

At the time, Shuer was working as a mental-health counselor for ServiceNet in Northampton and had served on the Western Mass. Hoarding Task Force for about a year. No one at work knew he had the problem, but in time he admitted to it publicly.

“I had to help others overcome the stigma,” he said, adding that he also received a grant to lead a peer-support group based on Frost’s book. After using principles outlined in the tome himself, Shuer began leading the group and meeting with Frost weekly, and they developed the facilitator guide to help others.

“By that time, I had learned enough to help myself and share what works,” he said. “What takes place in the Buried in Treasures groups is not therapy; it’s an action-oriented plan that helps people take concrete steps to alleviate clutter.”

Still, his wife struggled for years with her own issues caused by his problem. Although Belofsky Shuer has a degree in psychology from Smith and had some academic knowledge gleaned from one of Frost’s classes, she felt isolated and alone.

“The stuff Lee collected was so important to him that it put a real strain on our marriage,” she said. “I felt helpless in our home and insignificant; the things that made up my identity were buried under all of his things.”

Lee Shuer and Bec Belofsky-Shuer

Lee Shuer and Bec Belofsky-Shuer want others to know that TV shows about people with hoarding disorder do not present realistic ways to overcome the problem.

She added that most people don’t know there is help available that works. “Research only began in the ’90s, and TV shows that show forced cleanouts don’t work. But finding the motivation to change and learning why people become so attached to things and challenging their beliefs can make a real difference.”

However, the couple stressed that it’s not an all-or-nothing proposition; getting support from others online, through counseling, or in a support group with peers, which offers the best chance at success, can slowly lead to change.

Shuer said the disorder reflects an abnormal attachment to items that can stem from positive qualities that spiral out of control. For example, a person may feel they are archiving family treasures, don’t want to get rid of printed information they believe may prove valuable in the future, or be overly concerned about recycling things in a proper manner.

“There are emotional and cognitive aspects to decision making when it comes to letting go of things,” Belofsky Shuer explained, adding that the workbook outlines steps for decision making and is available free through their website, www.mutual-support.com.

“We encourage people to start small and focus on clearing one square foot at a time,” Shuer said.

Anyone whose problem hasn’t reached an extreme level can also begin by focusing on sorting through one type of item at a time: they could gather all the books in their home, put them in one place, then begin going through them.

“They need to remember they can get many of them at the library if they want to read them again,” Shuer told BusinessWest.

It’s critically important, Belofsky Shuer added, for family members to take care of themselves during the process. “I completely lost my identity and had a lot of anger and resentment when our home was filled with his possessions,” she said, noting that counseling allowed her to be supportive and restored her sense of self while her husband slowly worked toward their shared goals.

Course of Treatment

Studies have shown that people who hoard have suffered more trauma than the normal population, but only half have undergone a very difficult trauma.

“Trauma is not the underlying issue, but there is a lot of co-morbidity, and the biggest one is depression. More than half of hoarders suffer from it,” Frost said. “It isn’t clear that depression causes the problem, but it can make it worse.”

Laskey added that accumulating things can give people a feeling of control or enhanced self-esteem. She treated one woman with a very poor self-image that stemmed from her childhood who kept buying new clothing, even though she had never worn most of what she already owned.

“Buying gave her hope and a momentary feeling that included excitement and anticipation,” Laskey said, adding that the woman envisioned feeling attractive and confident wearing the new clothing, and lacked the confidence to think of other behaviors that could improve her self-esteem.

She suggests using stalling techniques before bringing anything new home, which can be something as simple as taking a walk.

“The problem is that the brain gets stuck like a record in a groove, and the need to have something becomes an automatic way of thinking,” Laskey said, explaining that, in some cases, the person can learn to be an “impartial spectator” by detaching from their feelings and trying to judge an item the way a friend might view it.

Indeed, asking a close friend for support can be beneficial, but it’s critical for that person to respect boundaries.

“If the person with the problem says they only want to spend 10 minutes going through things, don’t push them to do another five minutes,” Laskey said. “Let them set the ground rules and praise any progress they make. Hoarding is like an addiction which becomes a habit, and habits are really hard to break.”

Frost says three elements are critical to attaining lasting success. The first is controlling acquisition, and addressing the reasons why the person feels compelled to collect things.

“People see something they want, seek things out at yard sales, or find something while they are driving on trash day. Acquiring it is an impulsive behavior. When they find something they like, they get a high that is almost like an addiction; many people have told us it gives them joy in life when they find a new object to bring home,” he explained. “Their attention becomes so narrowly focused that they don’t think about whether they have the money to buy it, room to keep it in, or whether they already have a dozen of the same items at home.”

Treatment involves bringing conscious control into the decision-making process, but won’t work unless something else is substituted that gives the person an equal sense of pleasure.

Frost’s book Buried in Treasures contains a tear-out page with questions people can ask themselves to help them decide whether they should acquire a new item, and includes room for questions appropriate for individual situations that can be generated during therapy sessions or with a peer-support group.

The second key element in successful treatment is treating the overpowering urge and belief the person has that they must have something they see and desire.

“The urge is overpowering, but they have to learn to tolerate it, which is done by creating a hierarchy of situations in which they practice walking away from an item without buying it,” Frost said.

After acquisition and impulsive behavior are under control, the person then needs to pare down their existing trove of belongings.

“We work on changing the nature of the person’s attachments to things so it’s easier to get rid of them,” Frost noted, explaining that people often fear they will become depressed and unable to stop thinking about an item they get rid of, will never be able to find the same type of thing again, will lose an important connection to someone in their life, or will be responsible for harm coming to the object.

“So, we turn them into scientists whose goal is to discover whether their beliefs are true,” Frost said, noting that some clients get rid of one item, then keep track of what their life is like afterward.

“Some feel they will be anxious forever and won’t be able to stand it,” he told BusinessWest, explaining that putting long-held beliefs to the test is difficult for anyone to do.

Shuer said it was an epiphany to realize he could get rid of something and not miss it. “I thought, ‘If I can let go of one thing, maybe I can let go of others.’ The idea brought me a sense of joy and relief that I thought I could only get from acquiring things,” he said, cautioning that, when people begin weeding through their belongings, they should start with items that don’t have strong emotional meaning.

The third key element in successful treatment is learning organizational skills. People who hoard are taught how to create filing systems as well as ways to organize items that are important, as many lack knowledge in this area.

New Outlook

Today, whenever Shuer is tempted to bring home anything new, he asks himself whether he has a place for it, whether he can afford it, and what his wife will think.

“These questions are reality checks that have become automatic for me. I am less impulsive and have moved towards a long-term vision for acquiring things that fits in with my physical space,” he said.

His success has resulted in a new life mission and a better marriage.

“We are happy now,” Shuer said. “When you are living with too much stuff, you can never relax; you feel you should always be working to reduce it. But now that we are liberated from clutter mentally and physically, we have the time and freedom to have fun and help others.”

Indeed, the hope of finding peace of mind, improving relationships, and having time to enjoy life are real treasures that can motivate ‘finders and keepers’ to seek — and work toward — lasting change.

Business of Aging Sections

Difficult Decisions

Dr. Richard Alexander says screening for prostate cancer has become controversial

Dr. Richard Alexander says screening for prostate cancer has become controversial, but at least one study shows it extends longevity in people with the disease.

While much of what is known about prostate cancer is fact — including the fact that 99% of the men diagnosed with the most common forms of the disease will survive more than five years after diagnosis — there is still a good deal of conjecture. That’s especially true when it comes to screening for the malady.

One in seven men will be diagnosed with prostate cancer at some point in their lifetime.

“It’s a complicated disease, and a lot of issues surround it; doctors have devoted their entire careers to one subset of prostate cancer,” said Dr. Adam Tyson, a urologist at Urology Group of Western New England in Springfield.

Although it’s the second-most-common cancer in men and the second-leading cause of cancer deaths (skin and lung cancer, respectively, are number one), routine testing for the disease, which typically has no symptoms until it advances to the lymph nodes and bones, has become very controversial.

Screening involves a digital rectal exam and a simple blood test that measures the level of prostate-specific antigen, or PSA, which is a protein shed into the blood by the prostate gland that becomes elevated when cancer is present.

But in 2012, the U.S. Preventive Services Task Force declared that PSA testing should be abandoned. The reason is twofold: many men with elevated levels of PSA and an abnormal digital rectal exam have had biopsies that turned out to be negative, which caused unnecessary stress and did more harm than good; and arguments have been presented about whether routine testing increases survival rates.

Dr. Richard Alexander, a urologist at Baystate Medical Practices – Greenfield Urology, says a randomized study that followed a group of American men for 10 years found no difference in survival rates in men that were screened versus those not screened for the disease. But the problem with the study was that 70% of the men assigned not to be screened did indeed get screened outside of the study.

Dr. Adam Tyson says most prostate cancers are non-aggressive

Dr. Adam Tyson says most prostate cancers are non-aggressive, so the doctor and patient have to work together to figure out the best way to treat the disease, which depends on a number of factors.

In contrast, a very large European study conducted in many countries showed routine screening did lead to an increase in overall survival.

“It is not an easy thing to determine, and the results were astonishing,” Alexander said, noting that prostate cancer is found most commonly in men age and 60 older who often have two or more other diseases as well due to their advancing age, among other factors.

It can only be diagnosed by a biopsy of the prostate, which is done in a doctor’s office through the rectum using ultrasound guidance.

Alexander noted that an elevated PSA level increases the chance that cancer could be present, but it can be elevated by other factors that range from an enlarged prostate to inflammation of the prostate gland.

Neither the digital rectal exam or PSA level is a perfect test, but the American Urological Assoc. feels screening can be valuable for men between the ages of 55 and 70, especially if they are at high risk for the disease due to a family history, as it has a strong genetic component.

“I don’t think all men should be tested. But at age 50, they should have a conversation with their doctor about it, and if they ask for my recommendation, I tell them to get it done,” Tyson said, explaining that, since it is often a slow-growing cancer, it doesn’t make sense to test men over the age of 75.

“A lot of the cancers are non-aggressive and may or may not catch up with people, so the question is how to find men with aggressive cancer and treat them. Many men get biopsies who don’t need them, but if they don’t, the only other time the cancer will be found is in the late stages. And although most men with prostate cancer are more likely to die with it, rather than from the disease, there are still 26,000 men who die every year from it, and if it doesn’t kill you, it can keep you from being able to urinate, or spread to the bones and lead to fractures.”

He noted that a biopsy can be recommended with an abnormal PSA or abnormal exam.

“Often, the PSA will be repeated to confirm accuracy if it is elevated. But depending on many factors, a urologist may recommend a biopsy with a single abnormal PSA or an abnormal digital rectal exam,” he continued, explaining that, although prostate cancer is rarely found in men under the age of 40, he has seen it in men in their 50s with some degree of frequency.

Personal Decisions

The American Cancer Society says about 180,890 new cases of prostate cancer will be detected this year, and about 26,120 deaths will result from it. However, if it is caught in the early stages, it is treatable, and 2 million men who are alive today are prostate-cancer survivors. In fact, 99% of men with the most common types of prostate cancer will survive more than five years after diagnosis, and when the disease is localized to the prostate or just nearby, which occurs 90% of the time, the prognosis is even better; almost 100% will live at least five years.

But there is a great deal of fear surrounding the disease as well as myths associated with it, including the perception that prostate-cancer surgery means an end to a man’s sex life.

“When I tell someone they have cancer, that word is almost always the only thing they hear during our first conversation,” Tyson said. “It’s a life-changing event, so people with the disease need to work closely with their doctors.”

Alexander says men have choices about what will happen to them, but they need to have a clear understanding of the issue before making any decisions.

“People are terrified of the word ‘cancer,’” he said. “But many men can live with prostate cancer their entire life, while in others it progresses, and although there is no way to accurately predict the future, predictions have become more accurate than they were in the past.

“I encourage men to be aware of their options and make informed decisions,” he continued, adding he frequently hears horror stories from men who had a relative with the disease. Their initial instinct is to base their decisions on anecdotal evidence about what happened to that person, but decisions need to be made carefully, and both he and Tyson believe in seeking second and even third opinions after a cancer diagnosis.

“There is a risk in doing anything, but there is also a risk in doing nothing,” Alexander noted.

Symptoms that occur when the disease has advanced include problems with urination, loss of appetite, weight loss, and metastatic disease, which is the name given to a cancer when it has spread to the lymph nodes or bones.

But the disease has different stages as well as grades, which refers to how the cells in the biopsy look under the microscope and can indicate whether the cancer is likely to progress.

There are four treatment options available today: radical surgery, radiation therapy, hormone therapy, and active surveillance, which can include additional biopsies every year or several years. The age of the patient and their overall health and willingness to be treated help determine what choice is best. But they all have their own risks.

“A radical prostatectomy removes the entire prostate and attached glands, and the main risk is urinary incontinence and erectile dysfunction,” Alexander said, adding that the surgery is done if the cancer is still confined to the prostate, and the success rate is high. As to side effects, although most men have some incontinence following surgery, few are left with a permanent problem.

Radiation therapy can be done with machines over a period of weeks, and side effects include more frequent urination, burns to the bladder or rectum, and erectile dysfunction. The therapy can also be delivered by implanting radioactive seeds into the prostate. The radioactivity is gone within a year, but the metal seeds remain. The procedure requires anesthesia and takes about an hour.

“But not everyone is a good candidate for the seeds,” Alexander said, adding that whether someone is a candidate depends on the stage of the disease and how likely it is that the cancer will spread.

Hormonal therapy is reserved for more advanced cases, but this treatment has come a long way: decades ago, it involved removing the testicles, while today it is administered through injections. Possible side effects include hot flashes, muscle loss, fatigue, and loss of bone density.

“In some cases, hormonal therapy is combined with radiation,” Tyson said, noting that is usually done only in the case of advanced disease.

And although some treatments do cause erectile dysfunction, the problem has been mitigated by drugs such as Viagra and Cialis, which can improve the quality of a man’s life.

“The way a man urinates after any treatment will shift, and since the nerves and blood vessels involved in an erection are attached to the back of the prostate, any treatment will affect it. Sometimes there is only an occasional weakening, but most men will need medications to regain potency,” Tyson explained.

The final option for men with cancer is to do nothing other than be followed closely, and this choice is becoming more popular in cases where the disease is considered low-risk. “We are finding that prostate cancer can often be watched for years and never progress,” Alexander said, adding that hundreds of thousands of men who have the disease may never know about it.

Final Recommendations

Despite conflicting opinions, Alexander believes men with abnormal PSA levels should have biopsies. “I would rather know I had the disease and make a decision not to have any treatment than not know I have it,” he said, adding that the decision is an individual one, and although in most cases prostate cancer is slow-growing, that’s not always the case, as evidenced by the number of deaths from it each year.

Advances in the field have been made, such as robotic surgery, which is less invasive, involves less blood loss, and allows men to recover more quickly than they did before it was invented.

“When people hear the word ‘cancer,’ they go into panic mode, but it’s important to understand the nature of the cancer because every cancer has its own way of behaving,” Tyson said. “Most prostate cancers do not spread rapidly and are non-aggressive, so the doctor and patient have to work together to figure out what is right for the patient. There is no single right answer; some people absolutely need treatment, and in others, it is less clear.”

Indeed, there is a lot of choice involved in the matter, but the first step — which is to get tested — is something every man should consider and talk to his doctor about.

Business of Aging Sections

Lighting a Path


pathlightSPRINGFIELD — In a time of change for what, until recently, was known as the Assoc. for Community Living, the organization’s passion and innovative spirit will remain constants, its executive director says.

But it needed a name change, Ruth Banta went on, one that underscores the scope of the services it has provided to people with intellectual disabilities in the community — from youth through the senior years — since 1952.

That new name is Pathlight.

“What we’re hoping with the new name is that people will associate it with the breadth of the services that we offer,” she said. “When people hear that a service is a Pathlight program, we want them to know that means it is a caring, high-quality service backed by high-level expertise.”

Banta also announced that, in continuing the organization’s innovative spirit, Pathlight has partnered with Valley Venture Mentors (VVM) to offer the Pathlight Challenge. The two organizations have put out a national call to startup entrepreneurs to develop technology aimed at increasing independence for people with intellectual disabilities.

It’s expected that at least two proposals from startups will be accepted by Pathlight. Those entrepreneurs will be enrolled in Valley Venture Mentors’ four-month, intensive Accelerator Program in January.

“It’s a great partnership,” Banta said. “We’re tying our history of innovation and our passion for the people that we serve to entrepreneurs’ passion for innovation and breaking barriers.”

Paul Silva, chief innovation officer at Valley Venture Mentors, said what’s key in the Pathlight Challenge is that startups will have access to people in the populations they are hoping to serve as they produce their innovations.

“Interfacing with stakeholders is normally hard to do,” he said. “We have created a way in which companies that are worthy can get the access they need. If they want to develop something for parents, Pathlight can connect them to parents. If they want to gain access to staff, we can connect them to staff. This will allow them to troubleshoot problems as early as possible and allow their ideas to evolve more quickly. Pathlight is giving these startups a chance to be more competitive and, thus, more likely to survive.”

New Era

Formerly vice president of administration and chief financial officer at the organization that serves people with disabilities across Western Mass. from infancy through end of life, Banta said the name change to Pathlight was part of a rebranding that began last fall as a means of solidifying the agency’s persona and outlining its key values.

“Our mission is to help people on their own unique journey to experience the life they want to live,” she noted. “We weren’t being literal when we chose the new name, but we hope that it conveys that we shine a light on those journeys.”

Banta is excited about the partnership with Valley Venture Mentors, as it highlights the organization’s long-standing history of innovation. She noted that Pathlight’s history of advances dates back to its roots. “We were the first to open a community residence for people with disabilities and the first to create a shared living model for families.”

Now, she added, “we’re looking at how we serve the Millennial population of people with developmental disabilities and autism and looking at how technology can give these young adults the independence that they and their families want for them.”

The Pathlight Challenge is especially seeking solutions to issues regarding health, safety, and transportation.

“Transportation is often a big hindrance to the people we serve in terms of getting to jobs and recreational opportunities,” Banta said. “We’re looking to see how technology can offer assistance there.”

Silva said he is excited about the national call for proposals that will now be launched via both organizations’ databases and online connections. The selection process will continue through October.

The Accelerator Program is a four-month, intensive program held over one long weekend a month, offering startups connections to subject-matter experts, investors, and highly engaged and collaborative peers. Those competing in the program can win up to $50,000 in grants to develop their business or product.

The Pathlight fellows will graduate from the Accelerator Program in May, when they will also unveil their new technology, Silva said.

“To our knowledge, this challenge is the first of its kind,” he added. “There are hundreds of accelerator programs in this country running every year, but I haven’t run across any that are focused on assistive technology. Assistive technology is a new focus.”

One he and Banta — and plenty of clients — hope will continue to light a path to greater independence.

Business of Aging Sections

Shock to the System

DBS treatment

From left, Dr. Octavian Adam, Dr. Mohamad Khaled, and Paul and Kathie Schafer discuss the results of Paul’s recent DBS treatment at a recent press conference.

Paul Schafer’s wife likens it to “something out of Star Wars,” but it’s firmly in the realm of real-world science, and it holds the potential to change countless lives. It’s called deep brain stimulation, and for Schafer, who suffers from essential tremor, as well as many Parkinson’s disease patients, this treatment — now available at Baystate Medical Center — has opened a door to enjoying the activities of daily life most people take for granted.

Paul Schafer pressed a button on a small, handheld device, and started to shake.

The tremors were subtle at first, but within seconds his hands were shaking uncontrollably. When he picked up a plastic cup, the doctors sitting with him were grateful it was empty. When they handed him a pen to write his name, the scrawl couldn’t even be recognized as letters, let alone anything intelligible.

That was his life before his recent brain surgery, one of the first of its kind in the region. But when he pressed that button again — not without difficulty — the shaking stopped, and he was able, once again, to perform those simple activities.

That’s his life now.

“It changed my whole life,” said Schafer, 74, while sitting with his wife, Kathie, and the Baystate Medical Center doctors who facilitated that change. “All the mundane things you do every day, I wasn’t able to do without help — drink coffee out of a mug, brush my teeth, comb my hair, button my shirt … all the stuff everyone takes for granted. It was too challenging to do those things before the surgery.”

The procedure is known as deep brain stimulation, and it helps people like Schafer — who suffers from a common neurological movement disorder called essential tremor — as well as patients with Parkinson’s disease, dystonia, and obsessive-compulsive disorder, a chance at a normal life.

It changed my whole life. All the mundane things you do every day, I wasn’t able to do without help — drink coffee out of a mug, brush my teeth, comb my hair, button my shirt … all the stuff everyone takes for granted. It was too challenging to do those things before the surgery.”

The tremors caused by such conditions can be debilitating. But DBS, performed successfully — as Baystate neurosurgeon Dr. Mohamad Khaled did for Schafer — is opening up a dramatic new door to quality of life for potentially millions of sufferers.

The surgery — which involves drilling a small hole into the skull, under local sedation, and inserting electrical wires into the area of the brain where circuit errors are causing the tremors — may also hold potential in areas ranging from Alzheimer’s disease to severe depression, but those frontiers are still being studied.

Go HERE for a list of Skilled Nursing/PT Facilities in Western Mass.

The U.S. Food and Drug Administration approved the treatment for essential tremors and Parkinson’s in 1997, and it’s now recommended for patients with severe symptoms that don’t respond to medication anymore, or when the response isn’t sufficient, said Baystate neurologist Dr. Octavian Adam.

“Paul had symptoms for 15 years, and took a number of medications with some response; then the symptoms progressed and really affected his life in a negative way,” he went on. “He had difficulty using his hands — writing, holding a cup of coffee without spilling it, using a fork and knife to eat, brushing his teeth.”

Because the medications weren’t working anymore, the Schafers saw DBS as, well, a no-brainer.

“Dr. Adam was suggested by Paul’s previous neurologist, who said there may be something else we could look into,” said Kathie Schafer. “When we walked out of the building, we sat in the car, looked at each other, gave a big sigh, smiled, and said, ‘it looks like there’s a way — a better way of life.’ I think that was how we thought about the entire procedure.”

Finding the Sweet Spot

According to the National Parkinson Foundation, deep brain stimulation has proven to be an effective treatment for that disease’s symptoms, such as tremor, rigidity, stiffness, slowed movement, and walking problems, as well as similar symptoms present in essential tremor.

DBS does not damage healthy brain tissue by destroying nerve cells, the foundation noted. Instead, it uses a surgically implanted, battery-operated medical device called a neurostimulator to deliver electrical stimulation to targeted areas in the brain that control movement, blocking the abnormal nerve signals that cause tremors.

Dr. Octavian Adam, left, and Dr. Mohamad Khaled

Dr. Octavian Adam, left, and Dr. Mohamad Khaled say not everyone with tremors is a candidate for DBS, but those who are typically find the results dramatic.

The DBS system consists of three components: the ‘lead,’ an electrode — a thin, insulated wire — inserted through a small opening in the skull and implanted in the brain; another insulated wire passed under the skin of the head, neck, and shoulder, connecting the lead to the neurostimulator; and the neurostimulator itself, a sort of battery pack implanted under the skin, usually near the collarbone.

In the first phase of the procedure — called phase zero, because it doesn’t involve surgery — the neurosurgeon uses MRI or CT scanning to identify the area of the brain where the electrical nerve signals generate the tremors.

Phase one, as the next step is known, involves implanting the electrodes in the brain while the patient is under sedation. When the patient wakes up, Khaled asks him to point a laser at a target on the wall. As the doctor adjusts the electrical wires to target the appropriate circuit in the brain, the patient’s shaking hand slowly begins to stop shaking so that the laser is directly pointed in one location. That’s when Khaled knows he’s found the ‘sweet spot’ for the electrodes, and the patient suddenly is nearly cured of the tremors.

“The circuitry is in disarray, so you sort of shut that circuit down,” he explained. “Sometimes it’s like a radio dial — you need to dial it up or tune it down.”

After a few weeks of healing, a second surgical procedure is completed to make the changes permanent.  The wires are attached to a device implanted in the chest, which is programmed to send electrical impulses to the brain, which block the signals causing the tremors.

Not everyone with essential tremor or Parkinson’s is a candidate for deep brain stimulation, Adam explained. The best candidates have suffered from tremors for a long time and failed to find relief through medications, and the tremors have to be severe enough to impact their daily life in a significant way. “If those conditions are met, we consider surgery to treat them.”

That said, only about 10% of patients with essential tremor are good candidates, and 20% of those with Parkinson’s, though the calculation with Parkinson’s is a bit more complex, requiring at least some positive response to medications and a lack of other conditions, such as dementia, cognitive issues, and severe depression.

About 100,000 patients worldwide have undergone DBS since 1997. Previously, the closest hospitals in the Northeast that offered it are in Boston to the east, Albany, N.Y. to the west, Burlington, Vt. to the north, and New Haven, Conn. to the south. “So we had a big hole in the middle,” Khaled said.

That’s important, Adam noted, because patients with essential tremor or Parkinson’s are often unable to drive and may not have access to transportation, and the procedure is more than the surgical visits; many appointments are necessary in advance of the actual surgery. “Having it here makes it available to a lot of patients who would not have access to it otherwise.”

In Schafer’s case, he had hit the wall with medications; there was nothing else he could try. Despite the risks possible with any surgery, “I was very positive about the whole procedure.”

Still, the risks were minimal, Adam explained. In any brain surgery, the risk of bleeding or stroke is about 2%, and the risk of infection between 3% and 5%. “That’s pretty low. Ninety-five percent of the time, nothing happens. And this does not carry any extra risk compared to other brain surgeries; in fact, there’s less. The level of invasiveness is less. The electrodes are thinner than a spaghetti noodle.”

Science, Not Fiction

Schafer was also, naturally, curious about how long DBS would prove effective. Khaled and Adam explained that early response is always the strongest, and over time — perhaps a decade or more — some of the effect may start wearing off. But the device settings can be fine-tuned to provide better coverage and more control.

Paul Schafer

Paul Schafer speaks to the media about how DBS has allowed him to perform routine tasks that had become impossible.

In a Parkinson’s patient, the surgery’s effectiveness lasts between six and 10 years on average, but that disease’s symptoms are not limited to tremors, and those other symptoms progress regardless of the surgery. “So the management changes a bit,” Khaled said, “but studies show that quality of life with surgery is better than for those without surgery — that is, for the right candidates.”

Schafer knew he was one of those success stories when, right after the electrode began delivering signals to his brain, doctors handed him a flashlight, which he slowly — and accurately — lifted up to his mouth like a glass.

“We had tears in our eyes,” he said. “I wouldn’t have been able to do that with one hand.”

He shuts the system down to sleep — “when I turn it off, it’s a whole different world,” he noted — but restarts it in the morning and feels the tremors subside. He compares the feeling, when the neurostimulator switches on, to the tingle of a Novocaine shot, only throughout his whole body.

Today, he and Kathie say they understood both the potential and the risks — and there was really never any question.

“Of course, it does get a little scary, the idea that Dr. Khaled would drill into my husband’s head, but it needed to be done,” she said. “If there was a chance Paul could have a better quality of life going forward, then we were both very willing to give this a try.”

She’s glad they did, saying they’ve felt “nothing but happiness and wonderful excitement” as Paul rediscovered the ability to perform the tasks of everyday life with no difficulty. “We just keep smiling. It’s not without its risks or challenges, but to us, it was like something out of Star Wars. It was a miracle.”

Paul, now able to live a relatively normal life, plans to start a support group for people with essential tremor. “There are a lot of people out there with what I have,” he said, knowing that he can both share his experiences with those who might qualify for the surgery and at least bring together those who don’t. But he hopes more people fall into the former category than the latter.

“This has changed my life,” he said. “I strongly advocate getting the surgery done if you qualify for it. It makes so much difference.”

Kathie agrees. “He has a wonderful sense of humor, and he’s always been able to accept what happened with him and take it humorously and have everyone relax around him. But I knew it bothered him,” she said.

After letting Khaled, as she put it, drill into her husband’s head, “it’s made him 10 to 15 years younger in his attitude because now he goes out fully, completely aware of the fact that he can do whatever he wants to do, whenever he wants to do it.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections

Parental Guidance Suggested

Natalie, a Springfield mother

Natalie, a Springfield mother, is one of two women featured on murals for the “You’re the Mom” campaign.

Here’s a whopper of a statistic: according to the Centers for Disease Control and Prevention, about one-third of U.S. kids eat fast food every day.

But they’re not, for the most part, buying it for themselves; parents are making those choices.

That’s the issue that “You’re the Mom,” a new public-health campaign launched by ChildObesity180 at Tufts University, seeks to address. The campaign offers an array of messaging through various media, with one goal: get mothers thinking about the nutritional choices they’re making for their kids, and hopefully make better ones.

“We’re looking to increase the supply of healthier menu options for kids and create more consumer demand for those options,” said Linda Harelick, director of operations and communications at ChildObesity180. “We have engaged the restaurant industry and restaurant brands, and we’ve learned that there have been changes to menu options. Things have gotten healthier in the fast-food setting.”

However, she went on, “parents aren’t always aware of it. They get into the habit of ordering the number 7, or have their kids order a couple items off the dollar menu. Nobody’s studying the menu. We want to make them aware there are healthier options to choose from.”

In short, she explained, “we want to celebrate moms for the people they are and the role they play in families and communities — and give them simple tips.”

Harelick knows the issue is a complicated one, especially in a city with many low-income families living in neighborhoods underserved by stores selling fresh produce and other healthy options — a problem echoed by Kristine Allard, vice president of development for Springfield-based early-education provider Square One.

We want to celebrate moms for the people they are and the role they play in families and communities — and give them simple tips.”

“Particularly here in Springfield, where so many neighborhoods struggle with being part of a food desert, we know it’s not always easy to access good, healthy choices, and some families make fast foods their only option,” Allard told BusinessWest.

For families on a budget — often living near the poverty line — a visit to a fast-food drive-thru is often an exercise in filling up their children quickly at little expense, she went on. “But if we can make changes to what they order — swapping water for soda, ordering apple slices instead of fries, downsizing, not supersizing — that can make a big difference.”

She’s under no illusion that fast food is the best option for kids, “but if we can make small changes — and, in the long term, they make smarter choices — we can help reduce childhood obesity. It just makes sense.”

Square One is among a number of local organizations, including Partners for a Healthier Community and Springfield Food Policy Council, that are partnering with ChildObesity180 on the campaign, which is being piloted in the City of Homes, with plans to roll it out nationally in 2017.

Harelick recognizes that too few parents are immune to the combined pressures of packed schedules and picky kids bombarded with marketing for less-healthy options. But she believes the “You’re the Mom” campaign can make a difference, one choice at a time.

The campaign includes billboards, radio spots, bus advertisements, a heavy social-media presence (its hub is yourethemom.org), and murals by artist Marka27 — at 1072 State St. and 461 Main St. — featuring real Springfield mothers and promoting the message, “you’re the mom; you make decisions about what your kids eat,” Harelick explained.

The issue is nothing new to Partners for a Healthier Community (PHC), which joined several other community organizations eight years ago to launch Live Well Springfield, a movement to promote physical activity in area youth and increase access to healthy foods, a two-pronged approach to slowing a trend that has seen childhood-obesity rates triple nationwide and locally over the past few decades.

“What Tufts is doing is implementing a communications campaign that is very specific to low-income families with children who frequently eat at fast-food restaurants,” said Jessica Collins, PHC president. “If you have to eat at McDonald’s, make a healthier choice for your kid. Don’t buy soda; get water or milk. Give up the fries and choose apple slices. It’s another strategy to educate parents.”

Menu of Programs

Since its inception, Harelick explained, Child Obesity180 has brought in public-health advocates, industry and government leaders, and other nonprofits to design, pilot, evaluate, and scale initiatives intended to reverse the trend of childhood obesity — a full 180 degrees, in other words — within one generation’s time.

“We have very aggressive goals,” she admitted.

To get there, the organization has taken a multi-pronged approach. Among its initiatives:

• Its Active Schools Acceleration Project aims to increase physical activity in U.S. schools by identifying innovative solutions and giving schools the tools and resources needed to replicate proven models. For example, the New Balance Foundation Billion Mile Race has challenged students to walk and run 1 billion miles. “Five thousand-plus schools are participating in the campaign, driving excitement and interest in walking and running programs,” Harelick said.

• The Healthy Kids Out of School initiative works with afterschool enrichment organizations, like Boy Scouts, Girl Scouts, 4H, and youth sports leagues, to promote three principles: drink right, move more, and snack smart.

“Kids are eating more junk food than they need and not moving as much as they should, even in youth sports,” she noted. “We found if we communicated these three simple principles, we could have an impact. It’s been very well-received by the CEOs of these organizations.

“What we have learned is, we have to tie into the organizations’ values and practices,” she went on. “Scouts are looking to develop future leaders, and to be a future leader, you have to develop a healthy lifestyle. We developed a special healthy-habits patch for Boy Scouts and Girl Scouts, and developed a short online training for sports coaches.”

• The Restaurant Initiative, which is where “You’re the Mom” fits in, takes a three-pronged approach to reduce excess calorie consumption when children eat at restaurants: Increase consumer demand for healthier children’s meals, inform restaurant-industry leaders of the positive outcomes of increasing healthy menu offerings, and continue to conduct and disseminate original research.

• Another effort, the Breakfast Initiative — which promoted a healthy school breakfast and evaluated its impact on several key measures for children, including obesity prevention — completed its work in 2014.

That’s an area Square One knows something about, said Allard, who noted that many of ChildObesity180’s programs fit well into Square One’s mission of promoting well-being in children — not just academically, but physically and emotionally as well.

Linda Harelick

Linda Harelick says restaurant menus have gotten healthier and nutrition labeling has improved, but parents aren’t always aware of these changes.

“We know that kids who are well-nourished do well in school, so helping in a campaign like this, helping moms make healthy choices for their kids, is very much in alignment with our mission,” she explained. “Teaching kids to read, write, and be ready for kindergarten and academic success are very important, but we know there are so many more pieces than simply handing them a book.

“For many kids in our program,” she went on, “we provide two meals a day — breakfast, lunch, and two snacks — so we know they’re getting those meals with us, and we make sure they’re balanced and nutritious. But when they go home, they don’t always have those types of options. Access is the issue here, and budget is a challenge.”

Likewise, Partners for a Healthier Community, through the Live Well Springfield collective, has been trying to enhance school nutrition, from the preschool sector on up; make higher-quality foods, especially fruits and vegetables, more available in the city’s neighborhoods; and enhance urban agriculture and community gardens.

Live Well Springfield has also partnered with the city and the Pioneer Valley Planning Commission on improving area riverwalks, and has a hand in the city’s Complete Streets program, which is putting more sidewalks and bike lanes on streets. “People have to move around, basically,” Collins said. “That’s a national best practice cities are trying to do.”

Food for Thought

Harelick welcomes the partnerships with organizations like PHC and Square One. “We call ourselves a multi-sector organization,” she told BusinessWest. “We believe childhood obesity is an issue that can only be solved if everyone participates.”

In the case of “You’re the Mom,” which admittedly takes a narrow focus, “we saw an opportunity to address the issue of kids consuming excess calories in restaurants and at the same time improve the nutritional quality of selected meals,” said Christina Economos, director of ChildObesity180. “Moms have an enormous amount of influence on their kids, but sometimes they don’t feel that way. We want to support them and remind them that making small changes can add up to a meaningful difference in their children’s health.”

Harelick has significant experience in several sectors that are part of ChildObesity180. After an early career as a registered dietitian, practicing in clinical and research settings at Massachusetts General Hospital and Brigham & Women’s Hospital, she spent 17 years at Kraft Foods, overseeing strategic planning and marketing for iconic brands such as Maxwell House coffee and Post cereal. Upon leaving Kraft in 2008, she returned to academia to earn a doctorate in public health policy and management.

Having taken so many different views of the nutrition issue, Harelick is optimistic that her current organization’s goal — a full ‘180’ on childhood obesity — is within reach.

“We really believe that,” she said. “When we look at the problem of obesity, it seems very complex, but very interconnected. If you can influence one aspect of a child’s life, it has a wave effect on other aspects. And the more kids hear these messages, the greater the influence — it’s an echo effect.”

Beyond that, she said, “if we can impact culture in terms of the restaurant industry, convince them to offer lower-calorie foods, more nutritional quality, they’ll become societal norms for kids. It will become the norm to drink water on the basketball court, baseball field, or restaurant.”

Leaders at Square One — which, beyond its emphasis on healthy meals, offers an after-school physical fitness program called LAUNCH — say the work of ChildObesity180, and its new campaign, are effective complements to what’s already happening locally. “Our LAUNCH program is a health and wellness program for kids,” Allard said, “teaching them that fitness is fun, and that healthy eating can be fun and delicious.”

Just as Square One moves beyond talking about nutrition and fitness and actually provides opportunities for both, so Partners for a Healthier Community continues working toward greater access to healthy foods in the so-called ‘food deserts’ that tend to plague cities.

“The campaign bolsters work we’ve been doing locally, which is create access for families,” Collins said. “We have to start somewhere. It has to be both educating families to make the right decisions and also providing them access; if you just educate people, they’ll turn around and say, ‘but there’s no place to buy something healthy.’ That’s why the other strategies are so critical.”

Still, Harelick said, change begins with education, and she’s confident “You’re the Mom” will prove impactful enough to become a nationwide call.

“By delivering these messages and then reinforcing these practices at home,” she said, “we can really have a snowball effect.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections

Giving a Lift to Those Who Served

Jesus Pereira

Jesus Pereira founded Vet Air to enable veterans to “fly first class” to appointments at VA hospitals.

Dave Shields remembers that first flight being more than a little bumpy. And the plane’s cabin was even smaller than he’d imagined, and took a while to get used to.

Such sentiments, clearly not meant to convey dissatisfaction or disappointment, were to be expected, though. After all, while Shields was certainly no stranger to flying, his 21 years in the Air Force were mostly spent in and around the giant C-130 Hercules transport plane. In fact, the majority of his time serving in Vietnam was spent at Tan Son Nhut Air Base, just outside Saigon, training South Vietnamese crews in how to maintain the workhorse aircraft, which has now been in continuous use by the Air Force for more than 60 years.

It was his time in the service, which also included a lengthy stint at what is now Westover Air Reserve Base in Chicopee, that explains why Shields found himself in that tiny Cessna 172 just over a year ago. Well, that’s where the story starts.

As a veteran, Shields is entitled to receive care for service-related medical issues at the many Veterans Administration (VA) hospitals around the country (such as the one in Leeds) and healthcare providers affiliated with them, such as Yale-New Haven Hospital.

Diagnosed with cancer in his ear, Shields would eventually receive care at both the VA center in White River Junction, Vt., and Yale-New Haven. Getting to either place from his home in Greenfield, while certainly doable, was logistically difficult and quite time-consuming.

Or not, as things turned out, because of a unique nonprofit organization, based in Holyoke, that had just taken flight, quite literally. Called Vet Air, it recruits volunteer pilots to ferry vets like Shields to VA facilities along the Northeast corridor.

Jesus Pereira, founder, a veteran himself (Army Guard, with a 10-month deployment to Kuwait on his résumé), and one of those pilots, explains its basic mission and the many rewards for those who make it happen.

“These people served our country,” he explained. “This is something we can do for them to make things easier and less stressful for them and treat them like first-class, first-rate flyers. I love doing it, and all the pilots feel the same way.”

Pereira, who learned to fly at a tiny airfield in Turners Falls a dozen years ago, said that, to date, Vet Air is averaging maybe two or three flights per month, and has arranged maybe 60 in all. He has piloted roughly a quarter of them, and has taken Shields to several of his appointments.

He noted that, while the pilots are the ones who actually transport veterans to their respective destinations, it takes, well, an army of supporters, including area residents who support its various fund-raisers, to enable the agency to carry out its mission.

For this issue, BusinessWest took to the air with Pereira to gain some insight into Vet Air and its work, which is uplifting, in every sense of that word.

Plane Speaking

To call the flight from Northampton Airport to the even smaller field in Turner Falls a ‘short hop’ would be to greatly understate matters.

It’s 10 minutes door to door, or runway apron to runway apron, as the case may be. But Pereira, who flew BusinessWest to that small town just east of Greenfield to meet Shields — he was already doing some flying that Saturday afternoon and volunteered to do a little more — made the most of that time as he talked about Vet Air, its mission, and the challenges to meeting it.

Indeed, in between frequent bits of routine discourse with officials at both airports during the flights out and back, he explained that this agency is off to what all of those involved consider a very solid start.

Indeed, while only in business, if you will, for 18 months or so, Vet Air has already helped script a number of poignant success stories.

Jesus Pereira, left, with frequent passenger Dave Shields.

Jesus Pereira, left, with frequent passenger Dave Shields.

For example, there’s ‘Karen,’ an Army interrogator, who was severely injured when a prisoner she was questioning struck her with his handcuffs, breaking her jaw and causing damage to her eyes as well. Vet Air flew her to an appointment at a balance center, where she received specialized care in order to help her with her vision and balance.

Then, there’s Ben Bauman, a Marine from the Bay State who hadn’t been home to see his family in more than two years for personal and financial reasons; Vet Air took him on the last leg of an emotional journey home last Christmas.

To write such stories, Vet Air relies on volunteer pilots, said Pereira, noting that there is a small cadre of them who have made most of the flights to date, usually to the VA facilities in White River Junction and West Haven, Conn., although there have been other destinations as well.

There are three or four Western Mass. area pilots who take part, as well as a colorful individual from Maine who flies a pontoon-equipped plane nicknamed ‘the Moose,’ and handles a number of assignments in Northern New England.

“A lot of them do it because they have the time and means to just go flying,” he said. “But mostly they do it because they recognize the importance of what we’re doing and want to be part if it.”

In many cases, those being transported are veterans in the process of trying to determine if health matters are, indeed, service-related, he explained, adding that this process usually requires several visits to VA doctors, which explains why most Vet Air clients have used the service on multiple occasions.

Many of the servicemen and women who have found Vet Air are veterans of Desert Storm or post-9/11 campaigns in Iraq and Afghanistan, said Pereira, but some, like Shields, served in Vietnam.

Clients simply have to get to the airport closest to where they live, and Vet Air essentially takes it (or them, to be more precise) from there, he told BusinessWest, adding that it arranges ground transportation from the destination airport to the provider in question — usually in the form of a vehicle loaned by one of the airport’s fixed-base operators (FBOs).

There are certainly other means to take such vets to appointments at various providers, Pereira went on, adding that shuttles run between the VA hospitals to take individuals for specialized care at facilities where such services are provided.

“But taking the shuttle can often make a half-hour appointment take all or most of the day,” he explained, noting that a shuttle will make at least a few stops along its route to pick up additional veterans bound for the same destination. And it won’t return home until all those aboard are done with their respective visits.

A flight aboard the Cessna he usually pilots — it belongs to a friend, a flight instructor who lets him take it when he needs it  — can cut the trip down to an hour or two.

“We took a woman from White River Junction’s VA who had to go to the Traumatic Brain Injury Center on Long Island,” he noted, citing an example of Vet Air’s primary reason for being. “To drive from Northern Vermont to Long Island is quite a trip. Her appointment was six hours long, and to drive home after that — I don’t think most people could that, so now this becomes an overnight, with all those additional expenses.

“We flew her there and back the same day,” he went on, “and it cost them nothing.”

Soar Subject

This ability to chop several hours off a potentially day-killing visit caught the attention of Shields, whose first involvement with Vet Air centered on bringing it to the attention of other veterans, not securing a ride himself.

“I saw a quick news story about it on one of the local stations,” he explained, adding that his first reaction was to help create awareness. He did so by helping to secure the agency a presence at the annual camping and outdoor show at the Big E in the spring of 2015.

A few months later, though, Shields was diagnosed with cancer and had need for Vet Air himself.

He said there were other alternatives for getting him to the facilities where he was treated, but they involved far more time and logistics.

“This was the easiest way,” he explained. “The [VA] shuttle goes to West Haven, but it doesn’t go to Yale; with Vet Air, there was a courtesy car at the airport that took me right there. It’s a great service.”

Shields hasn’t had to dial Vet Air’s number in several months now, but the nonprofit isn’t far from his thoughts. In fact, he’s become an ardent supporter who has referred a number of veterans to the agency.

And it needs such assistance.

Indeed, as Pereira noted, it takes the help of many people to get that plane in the air and then get the client to the VA facility, said Vet Air’s founder, adding that, while the flyer’s time is donated, there are flight-related expenses — roughly $80 to $120 per hour in the air, depending on the plane used — that have to be covered.

There are other costs as well, he said, listing everything from the landing fees charged by some airports to the modest marketing efforts to bring attention to the agency.

Fortunately, Vet Air’s mission resonates with many individuals and businesses, he went on, citing, as just one example, the FBOs that will often donate a courtesy car, like the one Shields rode in, to get a veteran from the airport to a healthcare provider.

“Once they see what we’re doing and what the mission is, they want to be part of it,” he explained, adding that, moving forward, Vet Air needs more people to become part of its story.

The agency stages fund-raising events such as the recent Mother’s Day Bazaar at the Moose Lodge in Chicopee and a similar gathering coming up for Father’s Day, said Pereira, and also sells T-shirts bearing its logo on its website.

As awareness of the agency grows and need for its services escalates, fund-raising will become an ever-more-important focus, he explained, noting that those who want more information on the agency or wish to help can visit www.vetair.org.

Landing Lights

Like the plane Pereira was flying, Vet Air is certainly small in size as nonprofit agencies go, with a budget that extends to only five figures.

But it is having a big impact on the lives it has entered. That means everyone from the vets sitting in the back seat of that Cessna to the individual flying the Moose; from the families of those veterans to the individuals and related nonprofits who have helped make these flights possible.

Thanks to Pereira’s vision and the help of countless contributors, veterans in need of care are now flying first-class — even if the plane’s cabin is only four feet wide.

George O’Brien can be reached at [email protected]

Business of Aging Sections

Into the Light


Dr. Katherine White

Dr. Katherine White says tanning can be a difficult habit to break, due to the way it makes people look and feel.

In recent years, many teens have turned to tanning beds to enhance their looks on prom night and graduation day. But that practice is no longer possible, due to a new state law that Gov. Charlie Baker signed in February that bans anyone under the age of 18 from using a tanning bed.

Prior to passage of this measure, Massachusetts allowed teenagers between the ages of 14 and 17 to visit tanning salons with consent from a parent or legal guardian, and those under age 14 to tan if a parent or guardian was present.

However, research by the American Academy of Dermatology, the Melanoma Research Foundation, the American Assoc. for Cancer Research, and other prestigious groups have led to legislation in 42 states prohibiting young people from using tanning beds due to studies that prove exposure to artificial ultraviolet light before the age of 35 increases the risk of melanoma by up to 75%.

Melanoma is not only the deadliest form of skin cancer, it is the most common form of cancer in young adults 25 to 29 years old, and the second-most common form in young people 15 to 29 years old. It is also the leading cause of cancer death in women aged 25 to 30 and the second-leading cause of death in women between the ages of 30 and 35. In addition, ultraviolet radiation emitted by tanning beds can lead to basal-cell and squamous-cell cancer and cause wrinkles, lax skin, brown spots, and other signs of premature aging.

Dr. Catherine White, a dermatologist and founder of Hampshire Dermatology and Skin Health Center in Northampton, said dermatologists have been advocating for changes in the law for years, and herald the newly passed legislation, as well as the fact that the U.S. Food and Drug Administration proposed two new rules last year regarding tanning beds. The first would not only restrict use of sunlamps in salons to individuals 18 and older, but also mandate that users sign a certificate before their first tanning session and every six months thereafter acknowledging they have been informed of the risks to their health.

The second proposal would require sunlamp manufacturers and tanning facilities to take additional measures to improve the overall safety of their devices. Suggestions include improving eye safety by limiting the amount of visible light allowed through protective eyewear; improving labeling on replacement bulbs to ensure tanning facility operators are using the correct bulbs, which would reduce the risk of accidental burns; preventing the installation of stronger bulbs without recertifying and re-identifying a device with the FDA; and requiring all sunlamp products to have an emergency shut-off switch that users can easily find and identify by touch or sight.

Artificial tanning has become a $2.5 billion industry, so these measures are deemed critical to people’s safety. Approximately 7.8 million adult women and 1.9 million adult men in the U.S. tan indoors, and reports show that 35% of American adults, 59% of college students, and 17% of teens have used a tanning bed.

White acknowledges that most tanning salons are small businesses that are often owned by women and add vibrancy to local communities, and says it’s important to recognize that fact, but agrees with other experts that medical information regarding tanning beds must be transmitted to clients in a clear way that outlines the risks.

“The World Health Organization has said that ultraviolet light is a known human carcinogen,” she told BusinessWest. “Using a tanning bed is a dangerous activity and increases the risk of developing basal-cell cancer, squamous-cell cancer, and potentially life-threatening melanoma.”

Overcoming Obstacles

Dr. Richard Arenas, chief of Surgical Oncology at Baystate Medical Center, has seen patients in their early 20s with melanoma, and says researchers believe the intensity and type of ultraviolet radiation emitted by tanning beds may be forcing changes at an accumulated rate in cells. Environmental factors may also be at play, and some people may be more sensitive to UV light than others and have family histories that could predispose them to getting skin cancer.

Dr. Richard Arenas

Dr. Richard Arenas says the incidence of melanoma, which is a life-threatening cancer, is on the rise in young people.

“But the biggest challenge is determining at what age a person is capable of making a decision to acknowledge the potential risk of using a tanning bed,” he explained, adding that there has not been enough publicity about the dangers and the fact that the rate of melanoma is on the rise, especially in young Caucasian women.

White concurs, and says education needs to be ongoing, especially since tanning is part of youth culture; college students often rent limos and go tanning as a group, and she has heard of cheerleading coaches who bring their teams to a tanning salon prior to a meet.

“The light and warmth may feel good, and there may be social benefits, but the fact is, when ultraviolet light hits the skin, it damages genetic material,” she noted. “A tan is an emblem of injury, and is the body’s last-ditch effort to prevent DNA damage and protect against damage to the cells. Sometimes the body can repair the damage, but it’s not always possible.”

Still, most human beings love the sun, and the reasons for visiting tanning salons are complex and include societal reinforcements — people often tell others with a tan they look great — and many women consider going to a tanning salon a way to pamper themselves.

But the dangers that have come to light are clear, and the Commonwealth’s new legislation mirrors similar laws in California, Delaware, the District of Columbia, Hawaii, Illinois, Louisiana, Minnesota, Nevada, New Hampshire, North Carolina, Oregon, Texas, and Vermont that ban the use of tanning beds for all minors under 18.

However, experts say tanning not only is it a difficult habit to break, it can be addictive, which was documented in studies released in 2013 that show ultraviolet light increases the release of endorphins or feel-good chemicals that relieve pain and generate feelings of well-being.

“People like to tan. It’s calming, relaxing, and something that they may regard almost like a treat. And although most adults know it’s not a good thing to do, they have the right to visit a tanning salon. But they need information about the risks spelled out clearly,” White said, adding that dermatologists hope the FDA’s proposal to have adults sign consent forms acknowledging the risks of tanning beds will be adopted nationwide.

As for the addictive nature of the habit, researchers often compare tanning to cigarette smoking. “Both industries can injure customers, and it is to their benefit to start people young before they are able to make informed decisions. And both have an addictive quality which make them difficult to break,” White told BusinessWest.

Misconceptions also exist that range from benefits associated with ultraviolet light and vitamin D — experts say taking supplements is safer — to the fact that some people believe it’s a good idea to get a base tan in the winter before going to a sunny locale such as Florida or the Caribbean.

But that is indeed a myth. “There is nothing protective in going to a tanning salon before a trip, because each exposure increases the risk of developing skin cancer, especially in young people,” White said. “We know that intense ultraviolet exposure is more dangerous early in life than it is later on, and people with a history of childhood sunburns are at greater risk for cancer.”

Prevention is Key

Ultraviolet radiation is made of UVA and UVB wavelengths, or rays. UVA rays cause aging of the skin, while UVB rays are short, more powerful, and can lead to cancer.

The sun delivers both, but Arenas says tanning beds deliver a more significant dose of both UVA and UVB.

“The damage caused at a young age can carry forward for the rest of a person’s life. Tanning beds are an unnatural source of UV radiation and are dangerous,” he noted, adding that the propensity for problems may be exacerbated if people are fair-skinned, sport red hair, or have a lot of moles. In addition, the fact that people are living longer means they will have more exposure to the sun, so putting oneself in harm’s way at a young age is even more dangerous than it may have been generations ago.

Arenas urges people to be their own advocates when it comes to skin cancer, and said everyone should get a full skin checkup each year.

“Insist that your doctor examine your entire body, including the cracks and crevices,” he told BusinessWest, explaining that skin cancer can occur on the palms of the hands and bottoms of the feet, as well as in the genital and anal areas. “You really need to have respect for your skin. We can’t avoid the sun, but people need to appreciate the fact that it causes changes that could lead to skin cancer.”

White says people who love the look of a tan can achieve the same result with spray tans, bronzers, and gradual self-tanners, and since many salons offer spray tans, clients who have purchased tanning packages should ask to have their sessions converted to spray tans. She also advises people using tanning as a means of pampering themselves to think of other ways to reward themselves that they find equally relaxing.

“The bottom line is that skin cancer can be prevented, and the new laws will help,” Arenas said. “All it takes is good judgment.”

Business of Aging Sections

A Sense of Motion

Dr. M. Zubair Kareem

Dr. M. Zubair Kareem says BPPV can be managed, but it is a permanent condition, and symptoms can reoccur at any time.

Some 90 million Americans will experience a sudden onset of dizziness at least once, and about 50% of those may have a condition called benign paroxysmal positional vertigo. While it’s a permanent malfunction, symptoms can be treated and managed, which is why doctors say it’s important to educate patients about the condition.

About four years ago, Jeanne Tardit got up one night and suddenly became so dizzy, she couldn’t make it to the bathroom.

“It was really scary. Everything was spinning, and I felt as if I had no control over my body,” the 86-year-old recalled. “It was something I couldn’t live with.”

Tardit numbers among an estimated 90 million Americans who will experience dizziness at least once in their lifetime. It can be frightening, and the causes can vary, so it’s important to get an accurate diagnosis.

About 50% of people, including Tardit, who experience a sudden onset of dizziness have a condition called benign paroxysmal positional vertigo, referred to as BPPV or BPV.

Dr. M. Zubair Kareem, vascular neurologist and medical director of Holyoke Medical Center’s award-winning stroke program, said the symptoms can be treated and managed, but once BPPV occurs, it can return, because it is a permanent mechanical malfunction of a part of the internal ear.

It is diagnosed by taking a good history and examining the patient; tests including a CT scan or MRI of the brain are not required. BVVP is not life-threatening or something that can be resolved with surgery or medication. However, many patients get quite nervous when an attack occurs, and sometimes require an anti-anxiety medicine at least for a short period of time.

“It’s important to educate people about what BPPV is and how it can be managed,” said Kareem, adding that, although most people associate only hearing with the ear, the organ also serves as sensor for the coordination system of the body. Since the head weighs 10 to15 pounds, people could fall forward due to the change in the center of gravity when the head bends forward, and the brain makes appropriate adjustments, which include causing the back of the neck muscles to stiffen. The inner ear is part of the body’s balance system and helps with that adjustment.

BPPV results in a false sense of motion, or vertigo, due to inaccurate signals sent to the brain, which result in dizziness or spinning that can be accompanied by nausea, loss of balance, and blurry vision due to rapid jerking movement of the eyes.

It does not make a person confused or cause any paralysis, disorientation, pain, or speech or language problem, but some patients experience significant anxiety, which can be disabling. Symptoms may vary in each person, and they are typically brought on by changing the position of the body or head position, and often occur when a person looks up, bends down, rolls over, or gets out of bed.

About 2% to 4% of people experience BPPV in their lifetime, and the Mayo Clinic reports it is the cause of approximately 50% of dizziness in the elderly population.

Caitlin Eckhoff

Caitlin Eckhoff demonstrates one of four sequential head positions used in the Epley maneuver, which was designed to reduce vertigo.

Although it can be extremely uncomfortable and disrupt a person’s work and social life, the problem is usually treatable and can be helped with specific, easy-to-learn exercises that patients do whenever a dizzy spell begins. Kareem, along with other doctors and physical therapists trained in vestibular rehabilation therapy, often teach their patients to do these exercises.

In addition, Kareem employs something called the Epley maneuver, which was developed by and named after Dr. John Epley in 1980 and consists of a series of carefully orchestrated head movements. However, for the Epley maneuver to be successful, it is important to have a precise diagnosis and know the exact location of the malfunction.

Kareem does not recommend this maneuver to patients of advanced age or with neck arthritis. Patients unable to do the day-to-day exercises themselves may benefit from sessions with a therapist trained to administer vestibular therapy and the Epley maneuver, which can help keep vertigo from reoccurring or at least minimize the symptoms.

Mechanical Problem

Kareem says understanding BPPV involves a brief lesson in physics, and he frequently provides one to his patients using a detailed diagram.

“Basically, we have sensors in each ear that can detect our head’s movement or position,” he explained. “It’s important for the brain to know where the head is in space.”

Each ear has three sensors in the shape of tiny, semicircular canals that are filled with a jelly-like substance. One end of each tube is dilated, and its floor is lined with tiny hair cells topped by thousands of minuscule calcium carbonate crystals that are suspended in the gel, like a cloud hovering over them. When a person moves his head to the side, the weight of the crystals creates a ripple in the jelly, which causes the hair cells to move and initiates nerve impulses that are passed along the vestibular nerve to the brain to tell it the head is moving. When the brain receives this signal, it sends commands to the eyes, muscles, and the rest of the body that allow the person to maintain balance.

The system works well when people are young, unless there is a trauma to the head, but once people reach age 50, a significant number develop a problem because some of the tiny crystals break off, become loose, and settle on the floor of one of the ear canals. If that happens and the person moves their head in a certain way, the floating crystals send a false signal to the brain, which it reads as motion even though there is none. Normal signals transmitted by the moving hair follicles are subtle, but Kareem says signals from loose crystals are very strong, and the result can be a sudden onset of severe dizziness.

“It usually happens when a person gets up in the middle of the night or upon waking,” he noted, adding that BPPV typically occurs in one canal of either ear, although in some cases it can occur in both ears.

The brain is able to counter the false signal within seconds or a minute, but the vertigo, which can be severe enough to make the person feel like they are about to fall, can cause acute anxiety that can continue long after the spinning feeling stops.

Obtaining an accurate diagnosis is critical because dizziness can be caused by a number of other things. Kareem says a diagnosis of BPPV involves taking the patient’s history and administering a test called the Dix-Hallpike maneuver, which involves moving the head in a position that causes vertigo. This test can help localize the problem, but it may not be positive in every patient with BPPV.

Although no one wants to be diagnosed with a condition that can’t be cured, the good news is that the exercise, combined with the Epley maneuver, can move the loose particles into a part of the ear where they stop causing symptoms, which resolves the problem, at least temporarily, for about 90% of people.

“Once people understand the problem and know that it is not a serious, life-threatening illness, they feel comfortable managing it. With the daily exercise regimen, they feel significantly better,” said Kareem.

Tardif’s physician sent her to Attain Therapy and Fitness in Wilbraham, where she received vestibular rehabilitation. Her vertigo went away after a few sessions, and when she had another dizzy spell 18 months ago, additional treatments resolved the problem again.

Quality of Life

Lisa Blain, a certified vestibular therapist at Weldon Rehabilitation Hospital in Springfield, says many people suffer with BPPV for years because they don’t know it can be remedied.

Lisa Blain

Lisa Blain says tiny floating particles in the ear canal can lead to sudden bouts of dizziness when their motion is misinterpreted by the brain.

“The people I see have often been treated with medication or tried other things that didn’t work, and restrict their activity level because they fear moving too much will cause them to become dizzy,” she told BusinessWest.

“BPPV can be aggravating, irritating, and frightening, and a lot of people are unaware there is a treatment for it that works, but it’s important to have it correctly diagnosed,” she continued, mirroring Kareem’s statement and adding that different types of vestibular rehabilitation can be used for vertigo problems that result from concussions, stroke, or following long periods of immobilization.

She explained that the vestibular system, which is responsible for maintaining balance, consists of three parts: the central nervous system, the inner ear, and vision, which all need to communicate and work together seamlessly.

Blain advises people being treated for BPPV to bring someone with them and not plan on returning to work after a treatment because the Epley maneuver is designed to bring on dizziness, and the person may feel off balance after a session, even though the induced vertigo quickly passes. “It works well, but it can be uncomfortable in the short term,” she noted.

Caitlin Eckhoff, a physical therapist from Attain Therapy and Fitness who treated Tardif and specializes in vestibular rehabilitation, agrees, and says people often become anxious about the treatment.

She said it’s critically important for the therapist to know which ear and which canal is affected. “But 80% to 90% of patients have their symptoms resolved within two to six visits.”

Researchers do not know what causes the crystals in the ear to break off, and it can be difficult for people with BPPV to pinpoint what movements cause the onset of dizziness.

“For some, just going to the grocery store and moving their head around to find something on a shelf can cause a problem,” Eckhoff said, adding that doing exercises at home speeds the recovery process. “It’s a difficult issue for people, and a lot of people think they have to live with it. But it’s very rewarding to treat, as it’s the closest to an instant fix that I can offer someone.”

Indeed, in a day and age where people want problems resolved as quickly as possible, exercises and vestibular therapy can seemingly work small miracles.

Business of Aging Sections

Emperor of All Maladies Author Says the Pieces Are in Place

Dr. Siddhartha Mukherjee

Dr. Siddhartha Mukherjee says the so-called ‘cancer moonshot’ will provide a road map for advancing the fight against the ‘emperor of all maladies.’

As he delivered his talk, “The Changing Landscape of Cancer,” to a large audience at CityStage earlier this month, Dr. Siddhartha Mukherjee had a PowerPoint presentation running on a large screen behind him.

In a way, it represented a seriously condensed but still highly informative version of his book, The Emperor of All Maladies: A Biography of Cancer, for which he won the 2011 Pulitzer Prize for general nonfiction, and it led with what amounted to a trailer for the Ken Burns-produced PBS film documentary based on the book.

One of the slides, kept on the screen for several minutes, depicted one of the now-famous full-page ads that ran in newspapers across the country in December 1969 with the screaming headline: “Mr. Nixon: You Can Cure Cancer.”

While one might debate whether those spots legally constituted false advertising, Mukherjee implied, they certainly amounted to wishful thinking — very wishful thinking.

Indeed, neither the nation’s president nor anyone else could cure cancer 47 years ago, he explained, because the scientific community simply didn’t know enough about the disease to remotely approach that ambitious goal.

Mukherjee said those ads, inspired by and paid for by Mary Lasker, the noted health activist, philanthropist, and champion of medical research, were a prime catalyst for what he called “the war on cancer 1.0” — a war declared far too early to result in even partial victory, but one that set the stage for later triumphs.

“We had no understanding of the physiology of a cancer cell, let alone what caused it to turn cancerous, and yet a war on cancer was launched without that understanding,” he told his audience, there, as he was, to celebrate the expansion of the Sr. Mary Caritas Cancer Center. “People have often said that this is like saying, ‘we’re going to the moon’ without having seen a jet engine; that’s what the situation was like.”

Nearly a half-century and seven U.S. presidents later (many of whom have declared what amounted to their own versions of a war on cancer), the situation is much different, said Mukherjee, because the world knows exponentially more about the physiology of a cancer cell and why a cell becomes cancerous.

And this new landscape certainly provides more optimism for the latest declared war on this disease — the so-called ‘cancer moonshot’ (a term that only reinforces Mukherjee’s analogy) — that was announced in January.

“We understand cancer at a cellular and molecular level that we didn’t understand before,” Mukherjee told BusinessWest prior to his talk. “We understand what causes cancer, we understand its progression, we understand some, but not all, of its risk factors, and we have not one, not two, but really several dozen important breakthrough therapies for several forms of cancer.

“The question now is how to deliver those therapies carefully, how to deliver them to the right people, how to pay for them, and much more,” he went on. “Meanwhile, there are many cancers that are difficult to cure and difficult to treat, and they will remain frontiers.”

In essence, the cancer moonshot is expected to yield a road map (a term Mukherjee would use early and often) — actually, several of them — for crossing those frontiers and answering all those questions, he went on, adding that this initiative will bring new layers of progress to what he called a “transformative impact” on understanding and treating the many cancers seen over the past half-century.

For this issue and its focus on the business of aging, BusinessWest took the opportunity to talk with one of the world’s leading cancer physicians about the stunning progress achieved to date and how the next chapter in cancer’s biography will unfold.

A Hard Cell

Reducing a few thousand years of conflict between humans and cancer down to a 55-minute presentation wasn’t easy, but Mukherjee, an assistant professor of Medicine at Columbia University and staff physician at Columbia University Medical Center in New York City, managed by focusing on basic science, the milestones in the history of cancer treatment, and the people who made them possible.

Thus, his powerpoint featured slides on everything from surgeon William Halsted’s 19th-century “radical mastectomy” to Mary Lasker’s newspaper ads, and on everyone from Rudolph Virchow, often called the father of modern pathology and noted for his early work on leukemia, to Sidney Farber, considered the father of modern chemotherapy, to Barbara Bradfield, a pioneer (she was patient zero) in the development of Herceptin, a treatment for breast cancer.

His lecture on the history of the disease and mankind’s attempts to cure it focused on several stages he detailed in his 594-page book. They include, more recently, ‘cancer as a disease of cells’ — the period roughly from 1860 to 1960; ‘cancer as a disease of genes’ (1970-1990); ‘cancer as a disease of genomes’ (1990-2010); and the current stage, ‘cancer as a pathway disease.’

He brought his audience from the first identification of cancer some 4,600 years ago by the Egyptian physician Imhotep to current events, including groundbreaking initiatives to rapidly determine the sequencing of genes in tumor cells, leading to new treatment platforms.

Describing what’s been accomplished to date, he used words such as “remarkable” and “unprecedented,” words he says are fitting given the resilience, complexity, and sheer uniqueness of the disease and each case of it.

“Every single cancer, at the genetic level and the genomic level, is its own cancer, and every single patient is its own patient,” he explained. “We knew this 100 years ago, but we really learned this 100 years later.

“There is no disease — and I will argue that there are few problems in human history — where the level of diversity of the problem, the level of complexity of the problem, is equal to the number of people who have the problem,” he went on, urging his audience to consider the magnitude of what he just said. “Cancer is that problem … and that makes it different than any other disease, and that’s what makes it the emperor of all maladies.”

But while his book, and his lecture, amounted to history lessons, Mukherjee said his current focus is obviously on what comes next, and this brings him back to the cancer moonshot.

“This is an incredibly important effort,” he told BusinessWest before his talk. “It clarifies what the goals are, and that is to have a transformative effect on cancer care over the next 100 years.”

When asked what the initiative, officially named Cancer Moonshot 2020, might accomplish by that date, he said simply, “a line in the sand,” before elaborating and returning to that analogy of drawing a road map.

“What will happen over the next four years is that we will clarify that road map, which will hopefully stay with us for the next 80 to 100 years to remind us what the big goals are and whether we met the goals or didn’t meet the goals,” he explained. “We may at times go off the road because we don’t understand something, but as long as we have a sense of what that landscape is like, we can stay on track.”

Again, there will likely be several road maps drawn, he went on, adding that there are, indeed, several fronts in any war on cancer.

One is obviously treatment, he said, noting that considerable progress has been made with some cancers, including blood cancers — leukemia and lymphomas — as well as lung cancer, breast cancer, colon cancer, and prostate cancer.

Another front is prevention, which of course plays a huge role in the larger effort to stem the tide of the disease and greatly reduce the numbers of individuals who will die from it. And within the discussion concerning prevention lies the overarching question concerning whether cancer — or specific cancers — can indeed be prevented.

Some carcinogens, such as smoking, have been identified, said Mukherjee, adding that great uncertainty remains about how many more are still to be recognized. And this is a huge issue moving forward.

“That’s an open question on the table and a very important question: are there still out there major preventable chemical carcinogens — have we missed some?” he asked rhetorically.

“And if we haven’t missed some, what do we do about the fact that the rest of it is spontaneous errors, accidents when cells divide?” he went on. “That has many, many, many consequences, and there have been four or five highly controversial papers back to back in major scientific journals, one claiming the former, the second claiming the latter, one saying it has to do with cells making errors when they divide, the other making the claim that the environmental impact has been underappreciated, and there may be some hidden, unknown carcinogenic input.

“We need to sort that answer out,” he continued, “because it’s a fork in the road, whether we move in one direction or the other.”

There will be several similar forks to confront in the years to come, he said, adding that, beyond treatment and prevention, there are other large issues to be addressed, such as handling the cost of this battle, deciding how resources are to be committed, and drafting a plan for making this a truly international moonshot, not a solely American initiative.

Prescription for Progress

Almost immediately after Cancer Moonshot 2020 was announced, skeptics said it is as unlikely to achieve its stated goals as the initiative launched by President Nixon nearly five decades ago.

Mukherjee is far more optimistic. He notes that the pace of progress has greatly accelerated in recent years as more becomes known about the disease, and that enough will soon be known to not only draw a map, but enable society to reach its destination, one where cancer is far less the killer that it is now.

And he should know. After all, he wrote the book on the subject — a biography for which there are many chapters still to write.

George O’Brien can be reached at [email protected]

Business of Aging Sections

New Frontiers

Dr. Matthew Richardson (left) and Dr. John McCann

Dr. Matthew Richardson (left) and Dr. John McCann say Baystate’s clinical-trials program both helps current patients and advances research down the road.

When Linda Tedone was diagnosed in September with multiple myeloma, it wasn’t long before her oncologist at Baystate Medical Center, Dr. Syed Ali, came across an opportunity not available to many patients — yet.

It was a national clinical trial, one of dozens in which Baystate patients are enrolled at any given time. In Tedone’s case, her chemotherapy includes a drug, carfilzomib, that was FDA-approved in 2012, but only for relapsed patients who had undergone other therapies. Now, researchers are studying its effectiveness for first-time diagnoses.

“They explained it to me and my family, and we talked about it and were very interested,” Tedone told BusinessWest. “I have a lot of confidence in Dr. Ali. Being in a clinical trial, not only do I have him and his expertise, but lots of other great minds are involved in this, all watching my progress. And I’m reacting well to the medication; the chemotherapy is doing exactly what Dr. Ali wanted it to do.”

A robust clinical-trials program at Baystate — patients are currently participating in about 60 different ones — is available for both adult and pediatric patients, depending on need and what’s available, said Dr. John McCann, a medical oncologist at Baystate who works with adult cancer patients.

“Basically, we’re an academic medical center, so we’ve had a clinical-trials program here for quite a few years,” he explained. “The newer clinical trials are focusing on the specific molecular features of patients’ individual cancers and bringing new treatments to the cancer center that we can use. Because we have an entire team of clinical researchers working with us, we’re able to do sophisticated clinical trials right here at home, so patients don’t have to travel to go to another academic medical center.”

He cited, as one example, a new trial that seeks to evaluate three immunotherapy drugs given simultaneously for patients with advanced melanoma. “It’s very important that patients get really leading-edge clinical trials right here in Western Mass.,” he added, noting that Baystate’s clinical-trials division accesses national trials through organizations like the National Cancer Institute, the National Institutes of Health, and pharmaceutical companies.

And Baystate isn’t alone. When Cooley Dickinson Hospital merged with Mass General Hospital in 2014, it opened up a referral pipeline for oncology patients being treated at CDH to enroll in the kind of clinical trials Mass General has been involved in for decades.

“We joke that doctors frequently have hallway conversations, and we have the same thing, except the hallway is Route 90,” said Avital Carlis, administrative director of the Mass General Cancer Center at Cooley Dickinson Hospital, which opened last fall. “And these relationships are where our connections to clinical trials emanate from.

“I’m very excited that the Mass General Cancer Center will be integrated with the clinical trials available there,” she went on. “Our doctors constantly review cases, and if a patient has unique circumstances, they’ll reach out to their colleagues in Boston, and the doctors in Boston might say, ‘great trial available,’ or ‘perfect match’ or ‘we really should get them in this,’ and we can get our patients involved in these clinical trials. There is a huge spectrum of trials open to us.”

Mercy Medical Center, like Cooley Dickinson, will soon be able to access trials through a new affiliation — in its case, with Smilow Cancer Hospital at Yale-New Haven Hospital, with which is has signed a letter of intent to pursue a relationship that will enhance cancer care at Mercy.

The partnership with Smilow will create new opportunities for patients in Western Mass. to enroll in clinical trials for a wide variety of cancers, said Dr. Philip Glynn, director of medical oncology at the recently expanded Sr. Caritas Cancer Center on the Mercy campus.

Dr. Philip Glynn

Dr. Philip Glynn

“Trials are really important because people get a chance to see if a new treatment can help them — or help a population of patients in general,” he explained. “It’s almost like having a built-in insurance policy; you know you’re getting the most recent treatment. It’s been reviewed by experts, and you’re being very carefully monitored by your doctor.”

The downside, of course, is that previously unknown side effects may arise, and the treatment simply may not work.

“Ideally, you’re being carefully monitored so you can be taken off if it becomes clear it’s not working and there are another alternatives,” Glynn said. “Another downside is that some of these trials have placebos, and people don’t necessarily get the treatment they hoped they’d get.”

With more hospitals joining Baystate locally in providing access to clinical trials available nationwide, it’s a decision patients will increasingly have to answer.

Put to the Test

Simply put, Glynn said, a clinical trial is a research study, and patients participate to answer a question or help improve or advance treatment of a disease.

“In my field, oncology, patients volunteer for clinical trials that test new treatments, to see how they compare with current treatment standards. Sometimes they test lifestyle changes to see if it lowers the chances of getting cancer. Sometimes they test new ways of finding out if people have cancer — diagnostic studies.”

Typically, trials are divided into three types, he explained. Phase 1 trials, which are most commonly conducted in a university setting, aim to answer questions about safety in terms of timing, dosage, and side effects. Phase 2 — the type of trial most-often available locally — delves further into safety but focuses more on effectiveness. Phase 3 trials compare the new treatment with the current standard, by placing patients randomly (and blindly) into one group or the other.

Not everyone who wants to take part in a trial may do so, Glynn noted, due to any number of contraindication factors. “There are times people may want to be in a study but are excluded based on pre-existing conditions.”

But plenty are able to enroll, McCann said, noting that some patients inquire about what opportunities are available to try new therapies, while others are steered toward trials by their doctor.

“If a patient is eligible for a trial, we go through the process in detail and talk about risks and potential benefits,” he explained. “Then the patient makes the decision whether or not they wish to participate in the trial.”

Which means they’re well-informed of all known risk factors, he went on. “Every clinical trial has risks associated with it. We are committed to the highest standards in terms of minimizing risk and also explaining very clearly to patients what risks are associated with the treatment.”

In many cases, however, patients have reached a point of desperation, said Dr. Matthew Richardson, a pediatric oncologist with Baystate Children’s Hospital.

“For some conditions, where the prognosis with traditional medicine is poor or at least not optimistic, I think people are motivated to try new things,” he told BusinessWest. “They also realize it may help other children in the future. I think that appeals to many patients — that ability to help other families and other people’s children in the future.”

The goal of any clinical trial, particularly in phase 3, is to compare new treatments or tests to standard tests, and that can’t be done with just one or two patients; researchers need hundreds — and because certain pediatric cancers are so uncommon, no single center will be able to provide that, he explained. That’s why Baystate is part of the Children’s Oncology Group (COG), which gives patients there access to the same trials offered at other children’s hospitals across the country.

Richardson is one of several doctors — as well as pharmacists and people not directly involved in the medical community — who sit on an institutional review board (IRB) that evaluates clinical-trial opportunities to make sure they’re appropriate for Baystate, that the science is sound, and that potential risks are not worse than the standard treatment — or, if the risks are high, that the potential benefit outweights the risk.

“We conduct a very thoughtful analysis, through very extensive discussions, before a clinical trial even begins at the hospital,” he said. “And if a member of the IRB is involved in the clinical research, they’re not allowed to weigh in on approval.”

Expanding the Pipeline

An added benefit to clinical trials, Glynn noted, is that people feel gratified to be able to help advance new types of research.

“That’s absolutely true,” said Tedone, the Baystate patient. “I mean, this is definitely my journey, and I want to have success, but at the same time, I also know that, if this is going to work for me, it will work for other people and make their journey easier, too. I’m all about research, and we need to get rid of this horrible disease — get rid of all these cancers.”

Patients intrigued by opportunities to participate in this type of research have to be gratified by the new opportunities cropping up in Western Mass., from Mercy to CDH to, yes, a widening pipeline at Baystate.

We’re referring to UMMS-Baystate Health, a campus of UMass Medical School expected to open in Springfield in the fall of 2017. The project — a collaboration between the medical school, UMass Amherst, and Baystate Health — is intended to meet three goals: increasing access to students in Massachusetts seeking an affordable medical education, responding to the healthcare needs of the Commonwealth by increasing the number of Massachusetts physicians trained in urban and rural primary care, and applying academic research to improve population health, reduce health disparities, and make healthcare better integrated, more efficient, and more effective.

“It’s really a game changer for the region,” said Dr. John Schreiber, chief physician executive for Baystate Health, and one of the reasons is access to new avenues for clinical trials through UMass Medical School. “We’ll be able to offer patients in the Pioneer Valley much more than we have previously.”

And one of the goals for physicians coming out of the program is that they understand how to be part of a clinical trial and how to connect patients with experimental therapies. “We want to be able to access that across the Baystate system, not just in Springfield. The outlook is bright.”

With all the optimism over clinical trials, CDH’s Carlis stressed that eligibility criteria can be narrow. “What’s nice about our relationship with our colleagues in Boston is, many of these physicians are world-renowned experts in their field; they know these criteria backward and forward. So, if we think a patient might be eligible, there’s no assumption made until they speak with the people in Boston for a full criteria check.”

That said, the big picture is important. “Through clinical trials, we’re trying to identify where care is going in the future, what are the best combinations of drugs. It opens opportunities for patients they would not otherwise have access to.”

Glynn agreed. “Clinical trials are designed by experts to answer specific questions about therapies,” he explained. “It’s very important, especially today, because there are so many new therapies available for patients in oncology. We want to be able to offer patients as broad a spectrum of potential treatment options as we can.”

Seeking Answers

After all, Richardson concluded, these are matters of life and death.

“We’ve gone from acute lymphoblastic leukemia in children being a uniformly fatal disease to having some types of leukemia with a 90% cure rate,” he said. “And that’s only been through cooperative clinical trials.”

Tedone, who has been active in her trial for more than four months, tracks other cancer research as well.

“In the past few months, three new medications came out for my specific cancer; the FDA has approved them,” she told BusinessWest. “They’re making progress on my specific cancer by leaps and bounds, which is good news for me, that’s for sure.”

In the meantime, she said, “I’m being positive. I feel like I’m getting great care, and if I have lots of scientists watching me, that just more people on my side.” n

Joseph Bednar can be reached at

[email protected]

Business of Aging Sections

Age-old Arguments


Ann Weber

Ann Weber

When you become a ‘senior,’ defined variously as 60 to 70 or older, you become eligible for legal benefits that are not available to your younger compatriots.

While many of these laws are needs-based, some are not — for example, Social Security, Medicare, and others which are available to all of us. The following is a non-exclusive list of some of these laws which might be of interest.

Timing Social Security Benefits

When you turn 62, you become eligible for early withdrawal of Social Security benefits, and this is a great benefit for people who for one reason or another cannot continue to be employed or who do not have a long life expectancy. However, for individuals born between 1943 and 1954, the monthly benefit at age 62 will be 75% of the full monthly benefit at age 66.

If you can wait for benefits until you are 70, there is an additional 8% increase every year for the four years between 66 and 70. So, before making a decision about when to start collecting these retirement benefits, consider the differences, taking into account your estimated life expectancy and your financial situation. For people who can afford to wait or who are worried about outliving their resources, waiting to file might be a good option to consider.

Medicare Hospice

As you probably know, for beneficiaries who are 65 and older, Medicare pays not only for medical and hospital services, but also for some home services and medical equipment used in the home. Less well-known perhaps are the hospice services available to anyone with a prolonged, life-threatening diagnosis.

Although the diagnosis must state that death is likely within six months, hospice now allows not only palliative but curative care, with the result that many individuals end up renewing their eligibility for the program in six-month installments, sometimes multiple times, or graduating from the program entirely.

Hospice services include scheduled in-home care and emergency 24/7 care, which can often obviate the need for routine medical appointments and some emergency-room visits. In addition, Medicare hospice assigns a licensed, professional social worker to beneficiaries to help the patient and family deal with the social and emotional ramifications of an end-of-life illness. It is a comprehensive home-healthcare program, and it’s free.

Charitable Giving from Retirement Funds

As a general rule, any withdrawal from a traditional individual retirement account (IRA) results in income taxation of the full amount withdrawn. However, if you are 70 1/2, you can make charitable gifts from your IRA up to $100,000, receive a full charitable deduction, and have the amount contributed count toward your required minimum distribution.

If you are charitably inclined and meet the age requirement, this is a great way to partially fund your charitable gifts with money that would otherwise be going to Uncle Sam.

Declaration of Homestead

In Massachusetts, a homeowner receives automatic protection from unsecured creditors up to $125,000 so long as the owner or covered family member occupies or intends to occupy the property as his or her principal place of residence. With a declaration filed on the land records, this protection is increased to $500,000 in total for the property.

However, for individuals 62 or older, a homestead may be filed on each individual’s behalf, so, for example, for two homeowners 62 or older, the aggregate protection increases to $1 million.

Reverse Mortgages

A reverse mortgage is similar to a purchase mortgage in that it is a loan from a bank or mortgage company to an individual. However, instead of using the funds advanced by the bank for purchase of a residence, a senior homeowner (62 or older) can use a portion of his or her home equity as collateral and receive cash in return.

Reverse-mortgage payments are not taxable, nor are the payments considered countable income for purposes of MassHealth (Medicaid) eligibility. However, reverse mortgages have fees due upon origination and servicing fees annually which can be substantial, and the loan will have to be repaid with interest which has accumulated over the life of the loan when the homeowner dies or no longer lives in the home as his or her principal residence.

In the right situation, these loans can be life savers, but, because of the fees and technical provisions, it may be wise to consult with a knowledgeable attorney before committing.

Durable Powers of Attorney

Durable powers of attorney are used to allow one person, the agent, to act for another, the principal, in financial matters. These provisions can take place immediately or be triggered by incapacity. Though powers of attorney can be utilized by people of all ages, signing a durable power of attorney can be one of the most important steps you can take if you are getting older to make sure your financial affairs are handled by the person you want and in the manner you would choose.

Under the Massachusetts Uniform Probate Code enacted in 2012, power of attorney was given additional muscle.  Specifically, in the event of an unreasonable refusal of a third party to honor the authority of a valid durable power of attorney, the agent can sue for damages.  This can be really helpful if the failure to honor an agent’s directions — for example, in a sale or purchase of property — results in a loss to the principal.

There are many other laws and programs which are available to seniors on a needs-based basis which have not been covered here. Additional information can be found at local senior centers and various government agencies, or by contacting an elder-law attorney. n

Attorney Ann I Weber is a partner at Shatz, Schwartz and Fentin, P.C., and concentrates her practice in the areas of estate planning, estate administration, probate, and elder law. She is a fellow of the American College of Trust and Estate Counsel and past president of the Hampden County Estate Planning Council, and has been recognized by Super Lawyers, Top Fifty Women Attorneys in Massachusetts, and Best Lawyers in America; (413) 737-1131; [email protected]

Business of Aging Sections

Peace of Mind

Anne Thomas (left) and Joelle Tedeschi

Anne Thomas (left) and Joelle Tedeschi say it’s critical that the Garden at Ruth’s House tailors programs to the individual interests and abilities of residents.

While researchers have hope, so far there’s no cure for Alzheimer’s and many other forms of dementia — conditions that currently affect some 5.3 million Americans but could soar in frequency as the massive Baby Boom generation heads into the golden years. That trend places greater importance than ever before on memory-care units, specialized neighborhoods in assisted-living and skilled-nursing facilities that seek not only to care for residents with dementia, but strive to give them back as much of their old lives as possible.

It’s not always easy to walk in someone else’s shoes, especially when that person suffers from dementia. But at Loomis House in Holyoke, they’re trying.

The training program for Loomis employees who work in the memory-care unit includes a mandatory activity called a ‘virtual dementia tour.’ They’re put through a sensory simulation including shoe inserts to make their feet uncomfortable, hazy goggles that mimic macular degeneration, headphones pumping in white noise like a ringing phone and an ambulance siren, and gloves to impair sense of touch.

“Then we ask them to do tasks. They quickly understand the frustration,” said Lori Todd, Loomis House administrator. “What we try to teach them is, you’re experiencing this for 10 minutes; imagine this all day long. Some people call it sundowning, but after eight hours, I’d be frustrated.”

A perceived need for better training led to the adoption two years ago of new regulations for Massachusetts nursing homes. Specifically, workers in specialized Alzheimer’s and dementia-care units are now required to undergo at least eight hours of initial training to care for such residents, and four additional hours annually. Proponents noted at the time that increased training is critical because roughly 60% of nursing-home residents have some form of dementia.

Lori Todd

Lori Todd says Loomis House works to counsel and reassure families, who are often dealing with wrenching emotions around their loved ones’ dementia.

At Loomis House, which maintains two separate memory-care units totaling 41 residents — there’s always a waiting list — administrators have taken staff training seriously for much longer than that, Todd said. In fact, the way staff assesses and engages its Alzheimer’s and dementia population is indicative of a wider trend in senior care, one that acknowledges that dementia is not going away as the Baby Boom generation continues to stream into its retirement years.

For example, while many facilities place residents with dementia into one of three categories of memory function, Loomis uses seven, in order to develop as individualized and specialized a care plan as possible. “If you’re stage three, you may be able to do a 100-piece puzzle for an activity,” Todd said. “In further stages, you may still be able to do a puzzle, but it may be a four-piece puzzle so you’re not frustrated.”

That said, the goal is to maintain as much independence as possible for residents through an individualized plan that determines what activities will keep them active and engaged. “We have to get an understanding of who they were and what made them tick — basically utilize that information to develop a plan that will be of interest to them.”

Similar strategies are put into play at Ruth’s House in Longmeadow, an assisted-living residence operated by JGS Lifecare. It features the Garden, a 30-bed memory-impaired unit with a central kitchen and living area and an enclosed, secured outdoor courtyard.

“It’s very home-like, which is really important,” said Anne Thomas, vice president of residential health. “But the one thing that distinguishes us from others is our exceptional programming structure, which is really important to people with dementia. If they’re not given some structure, they don’t do well. They need that schedule, that routine.”

Joelle Tedeschi, executive director of Ruth’s House, explained that every new resident is evaluated by the resident care director to determine how they fit into the site’s programming, which includes sensory activities, art and cooking groups, cultural-enrichment programs, and much more.

“We try to find out as much as we can about each person and craft programs based on that,” Thomas added. “It’s about engagement, but also creating an environment as much like their real home as possible. All the things a person enjoyed before should continue here — it shouldn’t change.”

Like Todd, Thomas noted that the population is aging, and the number of Americans living with some form of dementia — currently 5.3 million — is only expected to rise, meaning more nursing homes and assisted-living facilities are making a commitment to taking care of this population.

“With dementia, unfortunately, there’s no cure in sight; we don’t see the disease going away,” Thomas said. “Our responsibility is to create a wonderful program. Boomers are very discerning; they have disposable income, and they expect a lot, and they should. We’re designing things that we as Boomers would want for ourselves and our parents.”

Individual Focus

That begins with meeting each resident where they are, Todd said.

“There’s a lot of emphasis on understanding that we are guests in the home of the people who move in here. When people come to the dementia unit, they stay here; this is their home,” she said, explaining Loomis’ long-time philosophy of person-centered care. “So, if they want to get up at a certain hour, they can have their medicine when they wake up, rather than right at 8 in the morning. The satellite kitchen is open 24 hours a day, and they can eat when they want.”

Tedeschi said the Garden provides a similar sense of autonomy, including no set times for going to bed or waking up, and a kitchen where eggs can be cooked to order at any time. “Some folks don’t want to be up early for breakfast, so we’ll make them breakfast right before lunch if that’s their preferred time.”

The touches of home — and even pampering — continue with amenities like a full-service salon, live entertainers who get residents singing and dancing, and rules that allow residents to bring their pets with them. In addition, family members often volunteer to lead enrichment programs.

“Just today, one of the resident’s families brought in some old tools, and the residents sat around and reminisced about their lives. There were tools there I couldn’t identify, but some of our residents worked on farms as children and worked all day with these tools, and they talked about it. It was one of the most beautiful things I’ve ever seen.”

The Garden also recently introduced holistic-wellness activities including Reiki, aromatherapy, and reflexology, all conducted by student volunteers, said Mary-Anne DiBlasio, sales manager at JGS Lifecare, who has a background in alternative health. Meanwhile, a small activity room is being converted to a sensory meditation room.

In addition, JGS Lifecare takes part in the Music and Memory program, which works with residents’ families to develop a personalized playlist of meaningful songs, which they can play on donated iPods.

“We’ve seen some remarkable success stories with it,” said Alta Stark, director of marketing and public relations. “One woman’s daughter said she could tell immediately if her mother had her music therapy that day because she could have regular conversations with her. She said that had not happened for such a long time — it was like getting her mother back.”

Thomas is equally effusive. “I witnessed something walking through one day on the weekend — a resident in memory care was weepy, crying, and she wanted to go home. A life-enrichment person came over and consoled her, reassured her, got her iPod and earphones … and it calmed her down immediately.”

Tedeschi said it’s always a challenge to customize individualized programs when dementia has such a wide range of stages. Some residents can live relatively independently but need to be in a secure environment, she noted, while others wouldn’t even know how to press an alert pendant if they need help. “We need to anticipate what their needs would be. We have to customize a program for everyone and continue to add services according to their care needs.”

The complexity of caring for this population is why the Department of Public Health pushed for the new mandatory-training rules two years ago. In order to comply, staff members must be trained in the foundations of Alzheimer’s and other dementias, communication and connecting with these residents, techniques and approaches to care for this population, the components of person-centered care, working with families, the dietary needs of residents with Alzheimer’s and other dementias, social needs and appropriate activities in the care of such residents, recognizing and responding to caregiver stress, and preventing, recognizing, and responding to abuse and neglect of residents.

“Everyone who works here — even maintenance and housekeeping — has to have 12 hours of training,” Todd said. “And I’ve seen the benefits in training, retraining, and sensitizing. The regulations are strict, but it benefits the residents; it really does.”

Family Burdens

No one wants to admit their parent has dementia, Todd said, but the services provided in a specialized memory-care unit are critical when that decision looms.

“Most people who live here are a little more advanced than you see at home, and they’re at risk being in the community. Really, it’s a safety issue, and the caregiver can’t do it anymore,” she explained, noting that Loomis House provides a continuum of care that includes hospice services near the end of life.

It’s emotionally wrenching, she added, when someone understands that their loved one doesn’t recognize them in the same way anymore, but noted that Loomis provides a social worker to help families process that experience, and family support groups that help each other through the transition.

“At first, there’s a lot of fear, guilt, and anxiety,” she went on. “Then they begin to trust us. They see they can go home at night and their parents will be cared for. They have to trust that our people are caring for their parents because their parents can’t always tell them.”

Thomas agreed. “Sometimes it’s harder on the family than on the person who has this illness, to see that person changing before their eyes. That’s why we offer support groups for families.”

In addition, as part of the admissions process, Tedeschi said, families help residents assemble a shadowbox of photos and memories, to hang outside their room. Not only do the boxes help residents identify where their rooms are, they give the staff a better idea of what that person is all about. Families also fill out a profile about their loved one’s likes and dislikes, interests and hobbies, to help the staff build a satisfying daily routine.

Once they’re comfortable in their new home, DiBlasio said, “family members don’t have to be full-time caregivers anymore. We let sons be sons, daughters be daughters, and we become the caregivers. If we know the idiosyncrasies of the person, we can become part of the family, and they look at us as part of the team.”

The worst feeling a loved one can have, Thomas said, is the idea that “‘this is my mother; there’s nothing left to her.’ We want to demonstrate that this person has a lot left, and we want to bring that out in them. That’s our job, to bring out the best in the person so the family can experience that as well. The employees that work here find it gratifying that they can make a difference in many small ways, just by getting to know the person.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections

Cause and Effect

Dr. Mitchell Clionsky

Dr. Mitchell Clionsky says many conditions can mimic attention deficit disorder, so obtaining an accurate diagnosis is critical before treatment begins.

People with attention deficit/hyperactivity disorder (ADHD) have endured all sorts of labels — lazy, stupid, even crazy — while dealing with the self-berating that accompanies an inability to stay focused and complete tasks. Enter the ADD Center of Western Massachusetts, which opened in the 1990s and today serves as a neuropsychological diagnostic practice, providing a pathway for ADHD sufferers of all ages to get the help they need.

Dr. Mitchell Clionsky often suggests two books to patients diagnosed with attention deficit/hyperactivity disorder, which is commonly referred to as ADHD. The first is Driven to Distraction, and the second is You Mean I’m Not Lazy, Stupid or Crazy?! The Classic Self-Help Book for Adults with Attention Deficit Disorder.

The second tome recognizes the fact that many people with ADHD have been labeled any or all of those things — lazy, stupid, or crazy — and that they also berate themselves for their inability to stay focused, complete tasks, or even make money, which Clionsky says is a common problem for small-business owners because they frequently start too many projects at once, fail to bill clients in a timely fashion, or become overwhelmed by bookkeeping and detailed paperwork.

“There is so much shame and stigma associated with ADHD,” said Clionsky, the board-certified neuropsychologist and co-founder of the ADD Center of Western Massachusetts in Springfield. “Children feel stupid if they fail an exam because they got distracted, skipped a page, or forgot they were supposed to multiply rather than divide. They often do their homework but forget to turn it in, and feel embarrassed and defensive when their parents reprimand them.

“But they are not lazy, and they are not stupid,” he went on. “They have a deficit that involves their brain’s ability to produce or release the chemical known as dopamine, which allows people to stay focused.”

The Mayo Clinic defines ADHD as a chronic condition that affects millions of children and often persists into adulthood. It includes a combination of problems, such as difficulty sustaining attention, hyperactivity, and impulsive behavior. Children with the disorder frequently struggle with low self-esteem, troubled relationships, and poor performance in school. It occurs more often in males than in females, and behaviors can be different in boys and girls.

Two years ago, the Centers for Disease Control and Prevention reported that up to 11% of children in the U.S. have been diagnosed with ADHD. Thankfully, about half of them will outgrow it in their teens and 20s, but millions of adults remain undiagnosed, and even if children improve, they may still exhibit some signs of the disorder throughout their lives.

However, many other medical conditions cause similar symptoms, and Clionsky said depression, anxiety, and trauma can lead to an inability to concentrate and stay focused. In addition, frequent bouts of tonsillitis that cause children to sleep poorly can make it difficult for them to concentrate and perform well in school because they are always tired. But a number of studies, including a recent one conducted by the University of Michigan, show that when children diagnosed with ADHD have their tonsils removed, half of them no longer exhibit the problematic behaviors.

The same situation can result if a person has obstructive sleep apnea.

“We recommend that many people have a sleep study done before they start taking medication for ADHD; in some cases, the symptoms resolve once they are treated for the apnea,” Clionsky noted, adding that the inability to get enough oxygen while sleeping can make people inattentive during the day.

“No one has ADHD until it’s been proven — it’s a medical problem that requires a careful and detailed evaluation,” he continued. “When it is correctly diagnosed and properly treated, children and adults can perform so well that it seems miraculous. But the diagnostic process is complex, and there is a lot of variability.”

He explained that ADHD appears to have a genetic component and tends to run in families; if a parent has ADHD, his or her children have more than a 50% chance of being diagnosed with the disorder, and if an older child has ADHD, their siblings have more than a 30% chance.

However, some people have two conditions that exist at the same time. For example, Clionsky says a person with ADHD and obsessive compulsive disorder may have everything perfectly lined up in their cabinets, but be completely disorganized in almost every other aspect of their life. Meanwhile, a child may be depressed and also have attention deficit disorder.

“It’s a neurologically based condition. But there is no blood test, litmus test, or MRI scan that can prove a person has ADHD, which is what makes a clinical diagnosis so complex,” Clionsky told HCN, noting that people who have a hard time concentrating due to ADHD can pay attention under novel or interesting circumstances. “A 7-year-old may act completely normal when his mother takes him to the doctor; it’s a novel experience, so the doctor doesn’t see the child exhibiting any of the symptoms she describes. But if the appointment took two hours, he would notice everything she spoke about.”

But since everyone occasionally exhibits traits found in people with ADHD, diagnosticians look for entrenched patterns of behavior that fall outside the range considered normal for their age.

Complicated Undertaking

Clionsky opened the ADD Center in the ’90s with four partners, who planned to provide all the services people with the condition might need. But they soon discovered most clients simply wanted a diagnosis, and when the evaluation was complete, they returned to their own physicians and counselors for medication and help.

So, today, the ADD Center has become primarily a neuropsychological diagnostic practice.

“We evaluate about 200 people each year and have seen more than 4,000 patients since we opened,” Clionsky told BusinessWest, explaining that children must be at least 6 years old because, prior to that age, there is not enough evidence for a diagnosis to be conclusive as most young children have short attention spans and are very active.

Testing done on the first visit takes one to two hours and begins by collecting in-depth information.

“We get a comprehensive history that includes the person’s academic, medical, psychiatric, and family background, and they fill out a detailed questionnaire and are asked to rate a variety of symptoms on a scale of one to five,” said Clionsky. “We also interview the individual who is being studied as well as their parents or spouse.”

In addition, the person suspected of having ADHD takes a 15-minute, computerized performance test, which is purposely designed to be boring. “It compares their vigilance and ability to focus and respond consistently against people of own their age, and is used to determine how capable the person is of staying on task,” Clionsky explained.

When those tests are complete, the results are tabulated. However, if the case is complicated by medical or psychological issues, several more hours of evaluation may be needed that include testing the person’s reasoning and looking at their learning and problem-solving skills, their ability to memorize things, their intelligence, and their emotional state.

In order to be diagnosed with ADHD, six out of nine diagnostic symptoms must be rated ‘moderate’ or ‘severe,’ and they have to have been present since before age 12 and have created problems in more than one area of the person’s life.

“The symptoms have to have interfered with their academic, occupational, or social functioning and can’t be due to another cause such as anxiety, depression, a trauma, or a concussion,” Clionsky said, explaining that the symptoms of a concussion can mimic ADHD, but are typically temporary.

He added people with ADD fall into two categories. The first group has attention-impairment problems that lead to disorganization.

“It’s not that they can’t pay attention, but they are easily distracted or lose focus if something is boring, routine, difficult to understand, or has too many variables,” he explained. “Adults with ADD often become distracted or impatient during lectures where there is no interaction. They also have trouble completing tasks; they begin one thing, get distracted, and start another, which leads to something else, without ever realizing their primary objective.”

The second group has problems related to hyperactivity and impulsivity. “It predisposes them to a higher likelihood of auto accidents, orthopedic injuries, and head traumas because of their risk-taking behaviors. They tend to engage in activities that stimulate the release of dopamine, such as motocross or mountain biking, and are more likely to be in trouble with the law,” Clionsky said. “They also tend to speed, jump red lights, and do things such as leaping off the walls of a quarry without knowing its depths.”

If a person is diagnosed with ADHD, Clionsky talks to them about the condition and how it is affecting their life. He also suggests appropriate medication, which they can get from their own physician, and may recommend counseling to improve their organizational skills. Educational planning is included in the center’s services for students, and academic accommodations are usually recommended, which may involve having them take tests in a separate classroom and allowing them extra time to complete the work.

“We also tell students with ADHD to sit as close to the front of the room as possible,” he explained. “Most tend to sit in the back, which makes it really difficult, because there is an ocean of activity in front of them, which can be distracting.”

The testing is repeated during a six-month follow-up exam, but the medication usually works. Side effects are minimal, and negative long-term effects of the drugs are almost unheard of, Clionsky said.

Coping Mechanisms

ADD is a developmental disorder that starts in childhood, and even though some young people learn to compensate with help from adults, in many cases, it catches up with them.

For example, adolescents who get extra help from their teachers or have parents who carefully monitor their schoolwork often do well in high school. But once they enter the adult world or go to college, they are unable to manage on their own.

“I see many clients who have left law school or college; they’re bright, but they are failing,” Clionsky says, adding that they miss class, don’t allow themselves enough time to complete assignments, and are often distracted and thrown off track during exams by something as simple as someone dropping a pencil.

He added that many small-business owners who work in the trades, including landscapers and contractors, have come to the ADD Center for help.

“They may be really good at their job, but they are not good business people. They are working 70 to 80 hours a week, but are in debt because they fail to collect payment for their bills or have too many things going on at once, which keeps them from ever finishing anything,” Clionsky noted. “People with ADHD are the most wonderful people in the world, but they frustrate others because they don’t return calls, are late coming home because they make too many stops, and are disorganized. They make dates and promises but forget about them, and although their spouses love them, they can’t count on them. So, resentment builds up, their home lives become very disruptive, and they have trouble retaining jobs or relationships.”

However there is an exception: If the person with ADHD is working on something they really enjoy, they can block out everything else, and many adolescents and adults exhibit this behavior when they are playing video games because they are fast-moving and demand total attention.

But Clionsky says it’s never possible to know for sure if someone has the disorder until a full evaluation is done. He recently diagnosed a 20-year-old with anxiety disorder whose mother was sure she had ADHD.

“She couldn’t seem to pay attention to anything or finish filling out college applications,” he explained. “But the real problem was that she was so anxious, she worried constantly.”

The example points out the importance of examining every factor of an individual’s life that could cause symptoms commonly seen in people with ADHD.

“Some children and people just have bad habits. They procrastinate or are disorganized, so we are very careful about what we diagnose,” Clionsky said. “But if it is ADHD, it’s a real medical problem, and treatment can and will make a difference.”

Business of Aging Sections

Practicing What They Preach

Employees engage in unexpected ‘stress wellness breaks

Employees engage in unexpected ‘stress wellness breaks’ in which they are told to stretch, take a short walk, do push-ups, or engage in other physical activities for a few minutes.

On June 1, Karen Drudi completed her first five-kilometer run.

It was her 55th birthday, and she took third place in her age group. “I call it my marathon, and I have the medal I won hanging on a doorknob at home,” said the executive assistant at Dowd Insurance Agency in Holyoke.

Drudi is proud of her accomplishment, and knows that running a 5K is something she probably would never have attempted on her own. But thanks to the Dowd Wellness Program, which kicked off at the beginning of the year for employees in the company’s main branch and all its satellite offices, she was motivated to take up the sport.

The program was created to inspire people to eat a healthy and well-balanced diet, exercise on a regular basis, and engage in stress-reducing activities. It has had a marked effect on participants, and led employee Cathy Sypek to start a ‘Couch to 5K’ running group to share her love of the sport, which Drudi and other non-runners joined, meeting after work to train at the nearby Ashley Reservoir.

“I had tried running in the past, but had never been successful. So I thought that, whether I completed it or not, it would still be a challenge,” Drudi said. “We started in April, and within a few weeks, I felt it was something I could achieve. There was a lot of camaraderie, and whenever someone lagged behind, the rest of the group encouraged them to keep going. And since Dowd’s program began, other people have tried things like yoga or lifting weights. It’s motivating when we get together and hear about the success of other people.”

Catherine Palazzo, the company’s Human Resources director, conceptualized the idea for the Dowd Wellness Program after listening to representatives from other companies talk about wellness initiatives during a group meeting.

“When I returned, I did some research on wellness programs and found they were good for overall morale, health, and team building,” she said, adding that she presented the concept to President and CEO John Dowd Jr., who approved it wholeheartedly.

Which means that the company now follows the advice it gives others.

“We tell our commercial clients to try to implement an atmosphere in their workplace that inspires employees to be safe and stay healthy; it results in greater productivity and fewer sick days, and is also beneficial as it shows employees the company cares about their people,” said Dowd. “So I thought that, if we are going to preach it, we needed to practice it.”

Palazzo began designing the program with help from fellow employee Lynn Ann Houle, and asked people to volunteer for a wellness committee.

“The intent of the program is to support the overall health improvement and morale of our employee population,” Palazzo said, explaining that programs and activities have been designed to raise awareness about health and nutrition and increase overall physical activity levels, with recognition and incentives awarded on a regular basis.

For this issue, BusinessWest talked with employees at Dowd about how they created this program, and why they believe it is a blueprint for other companies to follow.

Changes in Behavior

The wellness program, which kicked off in February, features a number of components, including a weekly online questionnaire. Employees who reply earn points for positive responses to a series of health-related questions. They are asked about their food choices, whether they consumed eight glasses of water each day, and if they have engaged in the listed exercises, which range from doing an hour of cardiovascular activity during the week to lifting weights, running, or doing yoga.

Every few months, the activities on the list are changed  — with advance notice — to inspire people to try new sports such as kayaking or hiking.

Points are tabulated, and prizes are awarded at a monthly luncheon, where people’s birthdays, anniversaries with the company, and other milestones, such as exceeding sales goals, are also recognized.

At that time, the grand-prize winner receives a gift certificate to a sporting-goods store, and second- and third-place winners choose from an array of exercise-related items, such as yoga mats, cookbooks, and videos.

In addition, food in the company snack bar has been changed; unhealthy items have been replaced with fresh fruit and other nutritious offerings. Free fruit is also put out once a week at lunchtime, and Houle announces unexpected ‘stress wellness breaks,’ in which employees are told to stretch, take a short walk, or do other physical exercises.

There are also periodic activities that allow participants to earn bonus points. In July, Houle planned a golf outing, and employees from different offices played 18 holes of pitch and putt at Annie’s Driving Range in Chicopee. She brought a fruit salad in a watermelon, as well as healthy beverages. “We all had a blast,” she said.

The following month, her goal was to “bring out the inner child” in each member of the staff, which led to the creation of Dowd Field Day.

More than a dozen people gathered outside the Holyoke office and played ladder ball and hopscotch, took part in a hula-hoop contest and a sidewalk-chalk art competition, then enjoyed healthy snacks prepared by committee members who used Weight Watchers recipes.

Houle said the event was truly enjoyable. “There is nothing better than laughter and a smiling face. It makes you feel good about yourself and is projected in your outward demeanor.”

This is what organizers had in mind when the program was launched at the annual company meeting. On that occasion, Dowd talked to the employees about why it was being implemented.

“I told them the firm is concerned about each person’s well-being, and we wanted them to take steps to improve their health,” he recalled. “We challenged them to begin an exercise regimen and to eat healthy foods, and told them, if the opportunity came up to participate in a walk for charity or something similar, to do it. Good health is achievable with exercise and proper diet and results in positive benefits.”

Each employee received a kick-off goody bag, with information on how to log their food intake and activity on myfitnesspal.com, as well as a stress ball, a healthy snack, bottled water, and other health and fitness items. In addition, everyone has been encouraged to complete Health New England’s annual online health survey.

Palazzo said participation has steadily increased since the program began, and enthusiasm continues to grow. To that end, the agency subsidizes gym memberships, and committee members share articles, healthy recipes, and information on physical activity and exercises that people can do at home.

Healthy Outlook

Houle is chair of the program and plays an active role in keeping people motivated. She told BusinessWest that she speaks to employees about how they are doing and sends periodic upbeat e-mails to keep everyone encouraged.

Houle lost 40 pounds on Weight Watchers two years ago, and said it enhanced her self-esteem. “It made me passionate about feeling good and being happy,” she said, adding that, as a result, she loves playing a leading role in the program because she wants others to feel equally good. “The people who choose to participate in this really enjoy it.”

Carol Andruss has lost eight pounds since the Dowd Wellness Program began by making small lifestyle changes, and said participating employees have lost more than 100 pounds overall, an estimate garnered through conversations in the office and at the monthly meeting and extracurricular events.

“I’m trying to watch what I eat and have been walking a few times a week, which is more than what I was doing before this started,” she said.

But it hasn’t been difficult, because she joined the committee and is responsible for stocking the office snack bar.

“I buy things like trail mix, low-fat pretzels, and popcorn,” she said. “And I pick up fresh fruit or fresh vegetables and hummus once a month for everyone to enjoy in the afternoon. I volunteered to do this because I wanted to raise awareness about healthy eating and become more involved at the office.”

Sypek, meanwhile, is a dedicated runner, and was so inspired by the program, and the fact that many employees began walking together as a group at lunchtime, that she decided to start the ‘Couch to 5K’ running program.

“I announced it in all of our offices,” she said, adding that the program has a set agenda — with intervals of walking, followed by running, then walking again — until the person can run three miles non-stop, which equates roughly to five kilometers.

Much to her delight, five non-runners decided to join. “We met five days a week for 30 to 45 minutes after work,” she said, explaining that each runner chose a 5K run they wanted to complete, and everyone has met their goal. “I love running, and this has given me a true sense of satisfaction. Many people think they can’t run, but they can, if they go at their own pace.”

Long-term Benefits

Employees who have chosen to take part in the Dowd Wellness program say it has been extremely beneficial and has resulted in positive life changes.

For example, Debbie MacNeal joined Sypek’s running group, which was a new activity for her. “I completed the Taste of the Valley 5K Run in West Springfield,” she told BusinessWest. “I’m pretty active and go to the gym a lot, but the 5K is something I would never have done on my own. It felt great to finish, and I am still running.”

Andruss is more conscientious about her food choices, and says walking with a group of people at lunchtime is motivating. “It has been proven that people are more inclined to exercise if they have someone to do it with.”

The weekly online survey has made Sypek more conscientious about the amount of water she drinks and whether she is consuming her fair share of vegetables.

“This program is great. Everyone needs to be reminded from time to time about things they can do to improve their health,” she said.

Dowd is satisfied with the results and plans to keep the program going. “A lot of people are participating, which is exactly what we hoped for. There is strength in numbers; it’s very positive, and the enthusiasm it has generated has been contagious. Plus, it’s important to practice what we preach,” he reiterated.

Palazzo is also pleased. “I’m happy there has been so much interest in our wellness program. It has really taken off and is good for employee morale and team building,” she said.

Houle agreed. “It has great benefits and shows that management cares about our overall well-being. They are willing to assist us by thinking outside of the box.”

Business of Aging Sections

Not A Primary Concern

Dr. Gina Luciano

Dr. Gina Luciano says there are many reasons why medical-school students are shying away from primary care, but she finds the specialty rewarding on many levels.

The problems causing a nationwide shortage of primary-care doctors — ranging from pay to prestige — are well-documented. Perhaps lesser-known are the reasons why medical students do choose this challenging, multi-faceted niche of medicine. Several young, local doctors have plenty to say about why they took the primary-care path at a time when a growing, aging population needs them most.

When asked about why students in medical school are shying away from careers in primary care, Dr. Gina Luciano was ready with an answer that would indicate she’s addressed that question more than a few times.

And she has.

That’s because, as co-director of the Primary Care Residency Track at Baystate Medical Center, the Springfield area’s only teaching hospital, she has chosen that field, she instructs those who have done the same, and, well, she promotes it as not merely a highly rewarding specialty, but one that is obviously critical within the broad healthcare system.

As for that answer … it comes it two parts basically, the first having to do with finances, and the second focusing on what she called the “culture of medicine.’ And they both help explain what most consider to be a problem and others are calling a crisis when it comes to attracting people to primary care.

“When most students graduate from medical school, they are hundreds of thousands of dollars in debt — I’ve had friends who are close to half a million dollars in debt by the time they graduate,” she noted while addressing the former. “And when you look at how people are paid, primary care physicians are near the bottom when you compare it to other specialties. So if you’re hundreds of thousands of dollars in debt, you may not want to go into primary care from a financial perspective.”

As for the latter, “many students and many residents, especially those who are excellent students, will be pushed to go into the most competitive fields,” she told BusinessWest, putting cardiology, gastroenterology, and other specialties in that category. “People will actually say to a year-two resident things like ‘why would you want to go into primary care? You’re so smart, you could go into ‘x’ or ‘y.’ I think there’s some sway from mentors and advisors in some institutions to go into something, quote, more competitive, unquote.”

As things turned out — although the decision certainly didn’t come easily, and, in fact, not until after she completed her residency at Baystate, one that included considerable work at the system’s High Street Health Clinic in Springfield, among other facilities — none of the above really mattered, or mattered enough to dissuade her from following what her heart told her she should do.

“The reason I chose primary care was because I realized that what I valued in my work was a continuous healing relationship with patients,” she explained. “I had developed these very important relationships with patients I had at High Street, and for me what’s most joyful about medicine is seeing people progress over time, and really understanding them — not just their health problems, but their whole person.”

Using that word relationship and the term whole person, or words to that effect, both early and often, other young doctors currently in or recently graduated from Baystate’s Primary Care Track, talked about why they chose the same career path as Luciano.

Dr. Kathryn Jobbins was actually roughly half-way through a residency in general surgery at the Cleveland Clinic, when she decided to not only switch gears career-wise, but return to the area where she grew up and the hospital where she worked years earlier.

“I thought I wanted that fast pace, but I missed talking to patients — and I missed my parents,” she said of her decision to begin another residency, this one in primary care, at Baystate. Fast forward more than three years, and she is now the internal medicine chief resident at Baystate and thus an instructor. Which means that, like Luciano, she splits her time between teaching and taking care of a number of patients at High Street, and, also like Luciano, greatly enjoys both aspects of her job description.

Among those she works with is Dr. Nicolas Cal, a second-year resident in the Primary Care Track who started down a path to be a neurosurgeon, but after some deep soul searching, changed course toward internal medicine, and specifically primary care.

“I decided to be 100% honest with myself … I didn’t think that neurosurgery was going to make me a very happy person 20 or 30 years from now, so I decided to change to primary care,” he said, adding that he has no regrets about that decision.

Dr. Kathryn Jobbins

Dr. Kathryn Jobbins says working in primary care offers a unique opportunity to work with patients over the course of many years, even decades.

Nor does Dr. Amulya Amirneni have any about hers. The native of India who immigrated here when she was 9 and later returned to her homeland for medical school, said she enjoys the very personal nature of primary care medicine, and said it amounts to “treating someone as an individual, as a person, and not as a disease.”

For this issue, BusinessWest talked with these young doctors about their decision to pursue a career in primary care, and about how and why they won’t be part of any problem or crisis in this field.

Course of Action

As she talked at length with BusinessWest, it became clear that Luciano has become as versed in talking about why she chose primary care as she is in explaining why increasing numbers of young people choosing to become doctors are not.

The relationship factor has a lot to do with it, she explained, noting again, that people in this field get to see the same patients over a span of years, if not decades, rather than perhaps a few days or even hours for those in other specialties. And thus they get to know those patients, and, as she said, the whole person.

“You get to see how their socio-economic background fits into their health, and how their family fits into their health, and how their culture fits into their health,” she explained, adding that the High Street facility, and Baystate Health in general, treat a wide demographic group and many challenged populations.

But there are several other aspects to this field that appeal to her, especially the variety of the work.

“The other reason I really like primary care is that it’s extremely broad,” she went on. “The pathology I see is really quite phenomenal; I see a variety of medical conditions at any given time.

“We have patients who have lived in the United States their whole lives, we have patients who have recently immigrated … this specialty really gives you the whole gamut of medicine,” she continued. “I enjoy that broad flavor.”

She also greatly enjoys teaching, and that’s why roughly half her time is spent seeing a portfolio, or panel, of perhaps 200 patients at the High Street facility, and the other half is spent helping young doctors navigate the three-year primary care residency track, which is part of the larger internal medicine residency.

There is room for 12 students in the program, or four a year, and there are currently seven enrolled in it, a number that speaks to the popularity of primary care, or lack thereof, said Luciano, adding that those who enter it understand those issues she detailed earlier, especially those involving finances and student loans.

But the doctors we spoke with said their choice has to do with passion, not money or prestige.

“I didn’t become a doctor for money … I became a doctor because I’m a bit of a science nerd and I like helping people,” said Jobbins, who probably spoke for everyone with those comments.

And that passion is a necessary ingredient in overcoming still another potential deterrent to those considering possible career paths within health care. Indeed, Luciano said those who enter a primary care track like Baystate’s often wind up working in residency clinics like High Street, which serve what she described as challenging populations for young doctors.

“Residency clinics have historically been places that have limited resources, the patients are disadvantaged, there’s a lot of pathology — there’s just not a lot of support for those patients,” she explained. “It’s generally Medicaid and Medicare patients, and taking care of those patients can be very tricky and challenging. So I think it’s very difficult for a resident who’s just starting out to navigate that system, but also to see how patients get better over time.

“It takes a longer time to see how you’ve had an impact,” she went on. “It’s much easier to be in the hospital and have someone come in to the hospital; you treat them, they get better, they leave — it’s much easier to see the impact that you’ve had on that patient. You don’t necessarily get to see that if you’re in a residency clinic.”

Dr. Nicolas Cal

Dr. Nicolas Cal transitioned into primary care after deciding that neurosurgery was not going to lead to the rewarding career he desired.

Jobbins agreed, but said she’s been motivated and energized by those challenges, and finds working in the High Street facility quite rewarding, and also intriguing.

Indeed, she said she’s very limited when it comes to Spanish, and doesn’t really know any of the other languages she encounters there, including Vietnamese, Chinese, and Nepalese, but has become quite adept at working with an interpreter in the room.

“I love the interpreters, and they do a great job,” she explained. “They do it almost live action — they’re talking while I’m talking. Some of my best relationships are with Hispanic patients, and we establish that through an interpreter.”

Overall, she’s looking forward to the prospect of treating the same patients for maybe 20 or 30 years, caring for them and being with them as different chapters in their lives unfold. And she said she’s already had a taste of how rewarding that can be.

“It’s wonderful, really,” she explained. “And it’s something you don’t really expect until someone stands up and hugs you or says ‘I just got my green card,’ or ‘my daughter is getting married.’ You see this very intimate snapshot into their life, which is very rewarding and a big part of why I decided to stay in primary care.”

Motivating Factors

And it is the unique nature of the primary care track, one that exposes residents to sub-specialists in their offices and teaches them not only about a wide range of medical conditions, but also teamwork and how and when to refer, that prompted her to pursue a teaching component through chief residency.

In that role, which she chose rather than moving directly into private practice, she serves as junior faculty and attending physician — essentially teaching while still learning.

“I fell in love with the program from an academic standpoint, and that’s why I decided to stay on as chief resident,” she said. “The goal is to do academic medicine with a focus on primary care when I’m done.”

For Cal, a native of Uruguay and graduate of New England Medical School in Maine, the immediate goal is to complete his residency and continue serving patients at the High Street facility.

While doing so, he envisions a career in primary care, hopefully in the Northeast. Like Luciano and Jobbins, he said he enjoys interacting with patients, seeing them over a long period of time, and helping them achieve progress with whatever health issues they may have.

“I love seeing my patients over and over and over again,” he explained. “I like dealing with different disease processes and knowing that I will have the time to follow up on my patient and adjust the treatment options to make the patient healthier.

“For example, yesterday, I had a patient at the clinic, a 34-year-old male, and I had to tell him he had colon cancer,” Cal went on. “As his primary physician and having to set up all the various specialists and appointments that he will have to go through — to me that’s very fulfilling.”

Delivering such news is one of many aspects of the job of a primary care physician, especially one in a setting like High Street, he went on, adding that another is being both “stern and compassionate,” as he helps patients within that constituency to understand various health problems and issues and compel them to take ownership of their own health.

“That’s a fine balance, and sometimes it can be frustrating for the physician knowing the patient may not be listening or fully grasping what will happen if he doesn’t change his habits,” he explained. “Our job is to motivate, and I like that part of the work.”

Amirneni hasn’t had many opportunities to motivate yet, having just started her residency a few months ago, but she said she’s looking forward to the opportunity.

“I definitely enjoy talking to patients and seeing them progress over time,” she said. “I know I’m more or less going against the trend when it comes to primary care, but the prospect of working that closely with patients and making a difference in their lives is what motivates me to stay in this field.”

“I’m really just getting started, so I’m hoping that I maintain that enthusiasm moving forward,” she went on, adding that, like Cal, she sees herself working in an outpatient setting when she completes her residency. “I really don’t think that will be a problem.”

Dr. Amulya Amirneni

Dr. Amulya Amirneni says primary care allows physicians to see their patients progress over time, something not afforded by other specialties.

Having enthusiasm and a desire to work closely with a patient are only a small part of the equation when it comes to the elements that make for a successful primary care physician, said Luciano, adding that these are simply pre-requisites.

“When I interview, I look for people who are compassionate, who are good team players, who want to make a difference in the world, who value relationships, and who want to see a continuous healing relationship with their patients,” she noted, adding that, like the passion that drives one to this specialty, many of those things can’t be taught.

“You can help people develop those skills, but for the most part, you either have them or you don’t,” she went on, adding that this is perhaps another reason why such individuals are in short supply.

Bottom Line

As she talked about her work and why she enjoys it so much, Jobbins said she’ll often challenge young residents thinking about sub-specializing to consider a different career track — hers.

“I’ll say, ‘why wouldn’t you do primary care? This kind of work is great,’” she told BusinessWest, adding that she gets a wide variety of responses to that query, most of them reflecting those two major points of concern that Luciano mentioned.

Whether more people will heed her advice in the years to come instead of following the money or the prestige remains to be seen. For now, there is a problem attracting people to this specialty, and, depending on one’s viewpoint, a crisis.

A solution will be hard to come by, but some young doctors are only interested in being part of one. They say they like forging relationships and treating the whole person.

So they have no primary concerns about their chosen field, literally or figuratively.

George O’Brien can be reached at [email protected]

Business of Aging Sections

Dementia and Will Contests


Talia K. Landry

Talia K. Landry

Most people have had some experience with a family member or friend who suffers from dementia. The term is used broadly to include a wide array of symptoms relating to decline in mental abilities. This often includes deterioration of both short- and long-term memory, along with lessening of cognitive and language skills, reasoning, and judgment.

Dementia can cause extreme stress and frustration not only for the individual affected, but for family, friends, and caretakers as well. Individuals experiencing dementia must often rely heavily on others for tasks they once accomplished independently. Some may even have difficulty communicating their needs and wishes. While the onset of dementia raises many questions related to daily life, it also raises special concerns in the context of estate planning.

It is important to note that, even when experiencing dementia, individuals are still capable of making many of their own financial and estate-planning decisions. The law presumes that we are competent unless a court declares otherwise. The law also recognizes that even individuals with severe dementia can have moments of clarity and lucidity sufficient to make decisions regarding their own affairs.

It is imperative, however, to use extreme caution when a person with dementia embarks upon the process of making or changing their end-of-life plans. In some cases, a dementia diagnosis received prior to executing documents can open the door for challenges down the road.

Consider the following example. Your mother is diagnosed with mild dementia — a diagnosis that appears in her medical records and history. She lives alone, and while she experiences some limited physical and mental decline that affects almost all seniors, she is still fiercely independent, albeit forgetful. Several years, grandchildren, and many happy memories later, she decides that she wants to update her last will and testament, which has not been addressed since her husband’s passing over a decade ago.

Your mother contacts her lawyer and has a new will prepared — one significantly different from the prior document. She leaves her house to your brother, who has helped maintain her home and yard over the years. She leaves you a sum of money equal in value to the house. She makes a decision not to leave anything for your estranged sister, who has not been in contact with her for many years. After your mother’s death, your sister becomes aware she will not inherit, and she decides to challenge the validity of your mother’s will. Although you feel sure that your mother was competent and lucid when she signed her will, the years-old diagnosis of mild dementia has the potential to undo her planning.

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Specifically, the law allows will challenges based on lack of capacity, undue influence, and fraud. If enough uncertainty can be shown, a court may decide that an individual suffering from dementia was not competent to understand what she was signing, or was pressured or tricked into signing it. These challenges can often turn into heartbreaking and protracted legal battles between family members, involving tremendous amounts of time, energy, money, and emotion for all involved.

No one likes to think about their family fighting after their passing, especially over money or personal items. Unfortunately, the courts manage this type of case all too frequently. Many families do not believe a legal battle will ever affect them, but sometimes even the best situations can turn sour. This possibility should be considered in many cases, especially when distribution may not be equal. Many potential heirs may feel that unequal bequests are unfair, and therefore ripe for challenges.

In order to pre-empt or refute possible future challenges, there are several precautions available when an individual with dementia seeks to complete an estate plan. First, it is important to hire an attorney. Forms available online are not ‘one size fits all’ as they often claim, and do not come with the benefit of advice tailored to your unique needs. Not only will an attorney be able to provide specific advice in accordance with the law, but the attorney can also serve as a witness attesting to the individual’s competency and the reasons why there may be a deviation from a previous estate plan.

Second, no one should be present in the room when the individual is discussing their affairs or wishes with their attorney, other than unrelated witnesses and a notary at the time of signing. This protects the proposed heirs and makes it more difficult to challenge a plan on the grounds of undue influence. Third, when capacity may be an issue, it is a good idea to have witnesses prepare written statements the same day, explaining the circumstances and what they observed. Fourth, with permission of course, it may be a good idea to record the meeting, so there is some clear evidence of the elder’s competency and ability to express her wishes at the time of the meeting.

Finally, it is important to keep records, including recent medical records, so there is some written or documentary evidence, should an issue ever arise in the future.

While we can never completely anticipate what will happen after death, taking some of these simple precautions can serve as formidable defense against later challenges, and may help in honoring a loved one’s final wishes.

Attorney Talia K. Landry is an associate attorney with Bacon Wilson, P.C. and is a member of the firm’s litigation department. She assists clients in all areas of litigation, with a specialized focus in probate litigation, including will contests, and other estate disputes; (413) 781-0560; [email protected]

Business of Aging Sections

Ready or Not


While rates of smoking and excessive drinking have declined among older Americans, prevalence of chronic disease has risen, and many older Americans are unprepared to afford the costs of long-term care in a nursing home, according to a report from the U.S. Census Bureau commissioned by the National Institutes of Health (NIH).

The report highlights those trends and others among America’s older population, now over 40 million and expected to more than double by mid-century, growing to 83.7 million people and one-fifth of the U.S. population by 2050.

Population trends and other national data about people 65 and older are presented in the report, which documents aging as quite varied in terms of how long people live, how well they age, their financial and educational status, their medical and long-term care and housing costs, where they live and with whom, and other factors important for aging and health.

Funded by the National Institute on Aging (NIA), part of NIH, the report draws heavily on data from the 2010 Census and other nationally representative surveys, such as the Current Population Survey, the American Community Survey, and the National Health Interview Survey. In addition, data from NIA-funded research was included in the report.

“This report series uniquely combines Census Bureau and other federal statistics with findings from NIA-supported studies on aging,” said Richard Suzman, director of the Division of Behavioral and Social Research at the NIA. The collaboration with Census has been of great value in developing social, economic, and demographic statistics on our aging population, with this edition highlighting an approaching crisis in caregiving — since the Baby Boomers had fewer children compared to their parents.”

A key aspect of the report is the effect that the aging of the Baby Boom generation — those born between 1946 and 1964 — will have on the U.S. population and on society in general. Boomers began to reach age 65 in 2011; between 2010 and 2020, the older generation is projected to grow more rapidly than in any other decade since 1900.

The report points out some critical health-related issues:

• Rates of smoking and excessive alcohol consumption have declined among those 65 and older, but the percentage of overweight and obese people has increased. Between 2003 and 2006, 72% of older men and 67% of older women were overweight or obese. Obesity is associated with increased rates of diabetes, arthritis, and impaired mobility, and in some cases with higher death rates.
• Research based on NIA’s Health and Retirement Study suggests that the prevalence of chronic diseases, such as high blood pressure, heart disease, chronic lung disease, and diabetes, increased among older people between 1998 and 2008. For example, in 2008, 41% of the older population had three or more chronic conditions, 51% had one or two, and only 8% had no chronic conditions.
• The cost of long-term care varies by care setting. The average cost of a private room in a nursing home was $229 per day or $83,585 per year in 2010. Less than one-fifth of older people have the personal financial resources to live in a nursing home for more than three years, and almost two-thirds cannot afford even one year. Medicare provides coverage in a skilled-nursing facility to older and disabled patients for short time periods following hospitalization. Medicaid covers long-term care in certified facilities for qualifying low-income seniors. In 2006, Medicaid paid for 43% of long-term care.

“Most of the long-term care provided to older people today comes from unpaid family members and friends,” noted Suzman. “Baby Boomers had far fewer children than their parents. Combined with higher divorce rates and disrupted family structures, this will result in fewer family members to provide long-term care in the future. This will become more serious as people live longer with conditions such as cancer, heart disease, and Alzheimer’s.”

Other areas covered in the report include economic characteristics, geographic distribution, social, and other characteristics.

“We hope this report will serve as a useful resource to policymakers, researchers, educators, students, and the public at large,” said Enrique Lamas, the Census Bureau’s associate director for demographic programs. “We sought to develop a comprehensive reference with up-to-date information from a variety of reliable sources.”

For more information on research, aging, and health, go to www.nia.nih.gov.

Barbara Cire is Public Affairs specialist for the National Institute on Aging.

Business of Aging Sections
Linda Manor Assisted Living Provides a Continuum of Care

Linda Manor Assisted Living was designed to be aesthetically pleasing — but this is an era when senior-living facilities must be much more than that. That explains the center’s focus on a continuum of care, its efforts to engage residents in activities inside and outside its doors, and its insistence on families being involved in decisions about the details of care — making what can often be a difficult life transition a little more like, well, home.
Linda Manor LobbyThe architecture and interior design of the newly opened Linda Manor Assisted Living facility in Leeds is breathtaking — and unusual for a facility of its kind.

The front doors open into a brightly lit foyer with high, coffered ceilings and comfortable sitting areas. A few feet away, a gracious twisted staircase climbs to an enormous, circular balcony on the second floor that surrounds the living area, and is punctuated by a large number of nooks with game tables and inviting couches and chairs, as well as a country kitchen.

The facility, which opened last October, has 85 units for residents, who can choose to live in a studio apartment or a one- or two-bedroom unit with their own kitchenette and private bath.

The 76,750-square-foot building features plenty for people to do, with activities that run the gamut from book clubs to art classes and exercise sessions; from volunteering at Kate’s Kitchen in Holyoke, which provides free meals to needy people, to day trips, such as a recent visit to the Sterling and Francine Clark Institute in Williamstown.

The lineup is dictated in large part by residents, who make decisions about what they want to do via committee, which they share with the activity director and write about in their newsletter.

“Our residents are civic-minded and want to be active; they may need some help, but they want to lead full lives,” said Kathy Herman, registered nurse and executive director of Linda Manor Assisted Living, or LMAL. “A few weeks ago, some residents wanted to spend the day going to tag sales, so we let them pick out locations and took them there. Having choices about what they do is important and makes them happy.”

But it is the continuum of care and philosophy that was established long before Linda Manor opened that sets it aside from similar senior living centers, she said.

Kathy Herman

Kathy Herman says Linda Manor’s small greenhouse was built for residents to enjoy.

It was built by Berkshire Healthcare, the largest not-for-profit company in Massachusetts, with 15 affiliates across the state and two hospices and a pharmacy serving clients. “We also have our own temporary staffing agency called Integra Nurse for our nursing homes,” said Albert Ingegni II, vice president of Housing Services. “This is more than bricks and mortar; we care about our residents, and, because we are a not for-profit corporation, we are driven by our values. Our residents always come first, and we try to make a connection with every one of them.”

Herman agrees. “It’s not just the resident who moves in. It’s the family that comes with them, and we stay in close touch with family members,” she said, adding that it’s important for children to know their parents are happy and that they can call whenever they have a concern. LMAL also boasts a van that is used to transport residents to doctor’s appointments, church, and other places they need or want to visit, which relieves stress on families.

The campus includes Linda Manor Rehabilitation and Nursing Center, so seniors who make their home in the new assisted-living facility have access to the above-mentioned continuum of care. Herman said it comes into play if a resident is hospitalized and needs short-term rehabilitation; staff from both buildings hold joint meetings about the resident’s health and well-being, and they can be easily moved back to their home when they are ready.

“Having both facilities on the same grounds allows us to integrate services and provide people with the most appropriate care,” she told BusinessWest. “We’ve established relationships between people in both buildings, which is wonderfully helpful to families, as they don’t have to coordinate care for their loved ones.”

Resident Berta Gauger enjoys living at LMAL. “It’s nice to have people around, and we travel and go places,” she said, adding that she looks forward to volunteering at Kate’s Kitchen.

Ingegni said a service plan is created for every resident that is assessed every six months or whenever the staff observes a change in behavior.

“We work to accommodate each person’s needs, and if they need more help than we can provide in the assisted-living section of the building, they can move into our Life Enrichment Program,” he added, referring to LMAL’s specially designed memory unit (more on that later).

Schooled by Experience

Before Linda Manor Assisted Living was built, Ingegni said, Berkshire Healthcare had decided to expand its housing component, and the Leeds campus, which already housed Linda Manor Rehabilitation and Nursing Center, was quickly identified as the ideal place to grow.

Many areas at Linda Manor

Many areas at Linda Manor are set aside for conversation.

“We wanted to provide post-acute-care services to this community and supplement the services Linda Manor was already providing,” he explained, adding that it is one of only a few senior-housing communities in the country designated by Medicare as a five-star facility, and was feted with the Gold American Healthcare Assoc. Award two years ago, which Kimball Farms in Lenox has also received.

Kimball Farms is a retirement community operated by Berkshire Healthcare, and offers housing that covers the spectrum of possibilities: independent living, assisted living, a memory unit for people with Alzheimer’s and dementia, and a skilled-nursing-care center.

Herman said it allows people to age in place, but, more importantly, the philosophy is one of “habilitation,” which means doing everything possible to help people maintain the level they are at when move in.

“It was developed by Joanne Koenig Coste, who wrote Learning to Speak Alzheimer’s, she noted. “We try to maximize success and minimize failure.”

Herman had retired from Kimball Farms before LMAL was built, but Ingegni talked her into returning to work so she could bring the successful program at Kimball Farms to LMAL and make sure it was well-established.

The Life Enrichment Program is an important component, and was created to take advantage of principles gleaned and perfected through years of experience at Kimball Farms.

“People with dementia often develop low self-esteem when they realize they can no longer do things they used to do. They get frustrated and bored, and, if they are dependent on others for all of their care, they feel like they have failed,” Herman said. “But if you provide them with an environment where they can be successful, they are happy, and it limits adverse behaviors.”

She explained that the Life Enrichment unit has a large kitchen that is central to the floor, a living room, and a sunporch that leads to an enclosed walking path bordered by gardens. “The residents can go in and out whenever they choose.”

Before new residents arrive, the staff obtains a detailed history of their habits, which includes the time they usually get up, if and when they eat breakfast, their daily routine, what they did during their lifetime, and activities they enjoy.

“We establish a plan of care around their schedule,” Herman noted. “They don’t have to do anything based on the clock, and if they want to eat lunch at 2 p.m. instead of noon, they can do it. If you have established a pattern in life, it’s hard to change when you’re 85.”

Special Measures

The staff undergoes continual training and holds frequent meetings to assess how each resident is doing.

“Our residents may have lost some of their cognition, but they don’t lose their emotions, so that’s where we meet them,” Herman noted. “We make them feel good about themselves, and if they don’t understand our words, they do understand body language, so if we are smiling and happy, it is reflected back.”

Resident Berta Gauger

Resident Berta Gauger enjoys volunteering at Kate’s Kitchen, among other activities at Linda Manor.

She added that staff members are carefully chosen, as not everyone has the temperament to work in a dementia unit, which requires thinking outside the box and coming up with solutions.

When Ingegni spoke with BusinessWest, 15 of 20 available spots in the unit were filled, and although it could have been built to house more people, he said it was designed to be small for a reason. “We found that, if there are more than 25 or 30 people, you lose your effectiveness.”

Although people with dementia are sometimes put on anti-psychotic medications while they at home, Herman said, when they are moved into an environment with people trained to meet their needs, in some cases, they can stop taking them.

“Alzheimer’s and dementia are a disease of the family, and the drugs are often given to make people sleepy, which allows the caretaker to sleep at night,” she said. “We look at the medications each person is taking and work closely with their physicians.”

Ingegni added that the way residents are treated starts with the behavior and attitude of management and filters down to each employee. “They set the example.”

For example, on a recent day Herman found a resident in the memory unit sitting inside while everyone else was outdoors. “I went to her room, got her sunglasses and hat, put them on her, and made a big deal about the way she looked. Then, I asked if she wanted to go for a walk,” she recalled. The technique worked, and Herman explained what she had done to the staff so they could emulate it if needed in the future.

“All of my managers are hands-on,” she said, citing another example that occurred when the dietitian was told a woman wouldn’t sit down to eat dinner. “The dietician responded by telling me she would prepare special finger foods so the resident could walk and eat at the same time, and she got creative with things like a salmon sandwich.”

In another instance, a woman who had been required to have a private aide at another facility because she was deemed a fall risk no longer needs one.

“She could still walk, but wasn’t participating in activities before she came here; she used to stay in her room. But now she is out all the time and hasn’t fallen yet,” Herman said.

Ingegni said the improvements registered by residents go back to the facility’s philosophy of habilitation.

“We want to keep everyone at their highest level,” he reiterated, citing examples like providing a typewriter for a woman in the memory unit who used to be a secretary and giving her paperwork so she felt she was needed.

Herman said the dedication of the staff is exemplified by the facilty’s bus driver.

“When he found he shared a love of poetry with one of the men in the memory program, he began coming back at night to read with him,” she said, adding that the driver also leads a support group for families of residents on the memory unit.

Moving Forward

LMAL has space available for additional residents, and Herman said the process of filling the complex is still ongoing.

But she and Ingegni are obviously proud of the new facility and believe it is off to a very solid start.

“It’s safe, it’s secure, and we are innovative and open to suggestions, so families can play an active role in what happens here,” Ingegni said. “And the fact that we offer different levels of care helps them and helps our residents.”

Which is exactly what everyone wants for aging parents who can no longer live in their homes: a place that caters to their needs and does everything possible to keep them healthy and engaged.

Business of Aging Sections
Mini Dental Implants Provide a Permanent Solution to Lost Teeth

Dr. David Hirsh

Dr. David Hirsh calls mini implants a fast, affordable way to replace missing teeth and stabilize dentures without surgery, pain, or bleeding.

More than 40 million Americans have missing teeth, and studies show the main reason is the cost: they simply can’t afford to replace them.

But thanks to advances in medicine, today people can replace their pearly whites with mini dental implants, which offer a permanent solution to the problem.

“They’re a fast, affordable, and permanent way to replace missing teeth and stabilize dentures — they don’t require surgery, there is no pain or bleeding, and they are half the cost of traditional implants,” said Dr. David Hirsh of Hirsh and Associates in Springfield.

This development is important because, in addition to detracting from a person’s cosmetic appearance, failing to replace missing teeth leads to other problems. Hirsh said the remaining teeth tend to migrate to fill in the space, which puts so much pressure on them, they can also be lost. “Filling in the spaces not only corrects how someone looks when they smile, it protects the remaining teeth and prevents the bone loss that occurs when they are not replaced.”

Mini dental implants, or MDIs, offer people with dentures a lasting solution to the problem of slippage because they provide an anchor to hold dentures or partials in place and gives them the strength and stability they need to eat foods such as corn on the cob or apples, which they would otherwise have to forego as they are too difficult to chew.

“When a person can only eat soft food because their dentures don’t fit well, being able to eat whatever they want in a restaurant is a tremendous change. If mini implants are holding the denture in place, they don’t have to use paste or powder, which they end up tasting more than the food, and there are no sore spots as the dentures don’t rub against the gums,” Hirsh said, adding that, when they are used to stabilize upper dentures, the palate portion of the denture can be cut away, which makes it much more comfortable and improves the taste of food.

MDIs are solid, one-piece, titanium-coated screws that take the place of a tooth root. They are much thinner than traditional dental implants and were originally designed to hold dentures in place. However, they have other benefits, including the fact that they stimulate and maintain the jawbone, which prevents bone loss and helps to maintain facial features. In addition, they are stronger and more durable than crowns and bridges that have been cemented into place.

They were first used in the ’90s and have been approved by the Food and Drug Administration for long-term use for fixed crowns and bridges and removable partial and full upper and lower dentures.

When Hirsh first heard about MDIs, he was skeptical. But after conducting research and learning more, he became convinced they could change people’s lives, so he attended classes in the Shatkin Fabricated Implant Restoration and Surgical Technique in Bufffalo, N.Y. and received his certification.

Six months ago, after rave reviews from patients, he said, he opened one of 27 Mini Dental Implants Centers of America. He told BusinessWest it is associated with the Shatkin Institute, which is the largest training center in America and has the largest lab and dental office in the country.

Dr. Todd Shatkin, who founded the institute, is president emeritus of the International Academy of Mini Dental Implants, and Hirsh is a member of that organization as well as the American Dental Assoc., the Massachusetts Dental Society, the Valley District Dental Society, and the prestigious Crown Council.

Hirsh said that, although traditional implants, which require surgery and months of healing time, were the standard of care for many years, a study by Shatkin that involved placing 10,000 mini implants in patients and following them for 10 years showed they had a 95% success rate, which is exactly the same rate as traditional implants.

The total cost of a single MDI in his center is $2,500, which includes the temporary and permanent crowns, while the cost of the four MDIs needed to hold a partial or denture in place is $4,000.

Something to Chew On

The process in Hirsh’s implant center begins with a panoramic X-ray, which allows the dentist to check the bone density and make sure there is enough room to place the MDI. Next, an impression is taken of the area that will be restored, which is sent to the Shatkin Institute.

“They fabricate a surgical stent that will be used to determine the exact spot where the MDI will be placed,” Hirsh said, noting that the institute also determines the size of the drill bit that needs to be used and the length and width of the implant.

When the patient returns to the office, the area is numbed, and Hirsh places the surgical stent, which is made of plastic, over the surrounding teeth. Next, he drills a hole through the gum into the bone and screws the implant into it, then secures a temporary crown onto it. “The color of the temporary is matched to the surrounding teeth,” he said, adding that, if any modifications need to be made, the information is sent to the lab before the permanent crown is created.

If the MDIs are being used to hold a denture or partial in place, it can be snapped onto the MDIs immediately after tiny holes about the size of a pen tip are drilled into the bone through the gum where the implant will be placed.

“Although a denture can contain about 12 teeth, you only need four implants to secure it,” Hirsh said, adding that, in cases where the denture doesn’t fit well, it may need to be modified before it can be used with the implants.

Losing a lot of weight can cause dentures to stop fitting properly, and if that occurs, people often find it difficult to keep them in their mouths. However, if the denture is secured by mini implants, it is not a problem. It will stay in place, and although people may want to get it realigned, Hirsh said the MDIs will never have to be adjusted.

MDIs have also helped many people with partials because they snap onto the mini implants, eliminating the need for metal clasps on adjoining teeth that hold them in place.

In addition, if people who are replacing a tooth have gum loss, crowns attached to the MDI can eliminate the cosmetic problem. “We put pink porcelain at the bottom or top of the crown so the tooth doesn’t look like it’s too long; it can be matched exactly to the color of a person’s gums and looks very natural,” Hirsh said.

He told BusinessWest the only instance in which a traditional dental implant works better than a mini is if someone has a very low maxillary sinus. “There may not be enough bone to put in the two implants that are needed, and in that case, we refer the patient to a local specialist. But it’s very, very rare.”

Evolving Science

Hirsh said misinformation has been circulated about MDIs in the general community, including the belief that MDIs can’t be used to replace molars or used for a full-mouth restoration, and only last about five years.

“They can last 20 years or a lifetime, just like traditional implants,” he noted, adding that they can be placed in people aged 17 and older once their jaw has stopped growing.

“I believe in 10 years, more dentists will use mini implants than traditional ones,” he said. “It’s a wonderful procedure that results in a wonderful cosmetic appearance. It’s just a matter of education; they’re life-changing.”

Business of Aging Sections
Innovative Method Helps Caregivers Engage with Clients with Dementia

Christina Vernon

Christina Vernon shows off just a few of the items she may include in ‘engagement boxes.’

As the over-65 generation is set to dramatically expand, so will the number of Americans suffering from Alzheimer’s disease and other forms of dementia. For those struggling with the cognitive and memory loss associated with these conditions, it’s beneficial to keep their minds active as much as possible. But how? Research by an intern at Homewatch Caregivers into a concept called ‘engagement boxes’ is setting a local standard for helping people with dementia hang on to memory, identity, and quality of life.

Christina Vernon calls it the “beach box.”

Inside are dozens of items that evoke the seashore — a jar of sand, a toy shovel and rake, a plastic bucket, a miniature beach ball, collections of seashells and sea glass, even a CD of beach-themed music.

To the average person, this array might evoke memories of a pleasant day soaking in the sun and the surf. But to someone suffering from dementia, the beach box may be nothing less than a catalyst for recovered memories and identity.

And it’s only one of dozens of such ‘engagement boxes’ that Vernon, a social-work student at Elms College, has carefully assembled for Homewatch Caregivers in West Springfield, where she works part-time, with the goal of focusing the minds of dementia patients through sensory stimulation and memory retention.

“These boxes hold items that trigger memories based on the five senses and promote conversation with people with dementia. It keeps them connected to conversation and lets them enjoy moments where they remember the past,” said Vernon.

For example, one brightly colored box might contain an old pair of white gloves, a child’s book of nursery rhymes, a small tea set, a beaded purse, and a jar of cold cream. “We might begin the activity by asking the client, ‘did you ever have a tea set?’ It may surprise you what your loved one comes out with.”

Sensory activities, she explained, involve many parts of the brain, including emotional, motor, and cognitive areas. They can allow someone with dementia to reawaken personal memories and help maintain the person’s quality of life, increase engagement with loved ones, and improve mood, behavior, and cognitive functions.

The key is to make sure the activities and conversations between caregiver and client are meaningful and individualized for each family.

“Nobody else is doing this, exactly,” said Judy Yaffe, co-owner of Homewatch Caregivers. “They’re very specialized for every client we’re working with. What happens is, we do a client history, get to know them a little more. We find out what they like and don’t like.”

Hence, the beach box would be ideal for a client who used to enjoy the beach or water activities. Other themed boxes contain baby-care items, art supplies, and vintage jewelry and toys — and Vernon often mixes and matches items to create individualized boxes to bring to clients. Caregivers engage the client with the items during visits, and, afterward, complete assessment sheets detailing what worked and what didn’t.

“The point of developing activities through the use of these boxes is to promote cognitive stimulation as an intervention for people with dementia,” Vernon said, noting that the roots of the philosophy can be traced back to 1950s research into ‘reality orientation,’ which was developed in response to confusion and disorientation in older patients in hospital settings.

Sensory exercises like the boxes Vernon maintains at Homewatch are coming more to the forefront in elder care as demographics are trending dramatically older. In short, Americans are living longer than ever before, with the massive Baby Boom generation heading into its golden years, and the number of patients with dementia — and, therefore, demand for services to assist them — are on the rise.

“Unfortunately, Alzheimer’s and dementia are going to increase,” Yaffe said. “We’re looking at a Baby Boomer tsunami.”

Engaging the Past

Engagement with dementia clients takes a variety of forms, Vernon said, showing off a pack of picture cards she uses during visits. She also shared a video of a session with a client in the early stages of dementia. Holding up a picture of stacks of coins,” she asks the client, “what is this?”

“It’s money.”

“Do you have money?”


“Where is your money?”

“The children took it.”

“The children took it? How many children? A boy or a girl?”

“Girls. The girls took it.”

“The girls took it. Hmm,” Vernon says, while switching to a card with a picture of a game of jacks. “Did your girls ever like to play with these?”

And so on — each image, each conversation pathway leading to another cue to engage the client. The boxes Vernon has assembled take the concept a step farther, by providing something to touch, feel, hear, even smell, in addition to viewing.

“She did this as a project for her school, an internship she developed,” Yaffe told BusinessWest.

“I was responsible to do a full research project for the company I was interning for,” Vernon said, referring to Homewatch. “Basically, I found myself working with dementia clients. So I decided to do my research on sensory stimulation boxes and memory.”

Judy Yaffe

Judy Yaffe, with a few of Homewatch Caregivers’ dozens of engagement boxes, says matching boxes with clients is a matter of learning their history, likes, and dislikes.

She bought several boxes worth of items on her own to test the concept. “I visited clients daily with boxes and researched what worked and what didn’t work. At the end of 16 weeks, [Homewatch] offered me a position 10 hours a week to create this program and run with it. It’s been very exciting.”

Since then, Yaffe has purchased most of the items for subsequent boxes. They include a collection of vintage toys, like a yo-yo and an original Slinky; to a “baby box” ideal for clients who love children; and a box of clip-on earrings from the ’20s, ’30s, and ’40s, which Vernon brings to a client who loves jewelry. “I made it a game; I ask her to put the pairs together, and then ask if she wants to try them on. It just keeps her active.”

In addition to the boxes, Homewatch has a growing collection of books, DVDs, and CDs of various genres and topics, all aimed at helping clients with dementia keep their minds stimulated.

“The items aren’t always cheap,” Vernon said. “When I go out, I make sure the client has at least three options, and if those don’t work, I go back and find something that does work.”

Sometimes that involves a bit of role playing. “When you’re working with a dementia client, if you’re comfortable entering their world, it really works,” she said.

Yaffe agreed, noting that each client is at a different place in their disease progression and how far back their memories lie. “We’re looking at where they are in their dementia. It could be back to their childhood, could be back to their first job, and that’s where we go. Entering the client’s world, to us, is really important.”

For clients at less-advanced stages, the more hands-on the activity, the better. “One was an avid artist in sculpture, so we bring him books about sculpture,” Vernon said. “We’ve bought sketch pads and watercolor pastels, just things to keep his mind as active as possible.”

It’s all about giving caregivers tools they can work with, Yaffe said. “We’ve developed quite a library here.”

Peace of Mind

While researching the effectiveness of engagement boxes at an assisted-living facility, interviewing five people over a period of weeks, Vernon — who will graduate in May and go on to pursue her master’s degree at Springfield College — came to understand the detrimental effects of an inactive mind.

“When you’re bored, when you’re not doing anything, when a client is sitting idle, their memories are fading faster than when they’re engaged with someone,” she said. “It’s better for the client’s overall well-being to be engaged. It’s great to see people light up, to see people talk about things based on the items we take out. It’s rewarding work.”

Yaffe said eliminating isolation and loneliness are two of the goals of her agency, and the engagement boxes are now a major component of that — not to mention a practice that family members can continue after a professional caregiver has ended a shift.

“Activities bring pleasure to people with Alzheimer’s,” Vernon told BusinessWest. “Keeping people involved in prior hobbies and interests that once gave them pleasure is important. Family members should take a flexible approach that is broad-based. Read the newspaper, look at books, cook, watch family videos — and remember to concentrate on the process of an activity and not the results. Perhaps develop your own engagement box for your loved one. It’s the joy of doing and discovery that can make the difference in their quality of life.”

Many clients don’t have dementia, but do suffer from some memory impairment, and the boxes — which can be checked out and brought back to Homewatch by families — can be effective tools for them as well.

“It’s really great for a family when they see mom or dad remembering something; it really gives the family a sense of purpose, as well as direction,” Vernon said. “We constantly exchange items and find out what’s working, find out what activities are good for a client.

“A lot of it is based on the individual person,” she continued. “I talk to the client and caregiver, spend an hour getting to know them, and after the initial meeting, I have a greater idea of what I can do to enhance their experience.”

Yaffe said Homewatch has long embraced other forms of sensory engagement with clients, especially music, which the Alzheimer’s Assoc. calls one of the main catalysts to recovering memory.

“We do a lot of music with our clients. If they remember something, it’s usually music from their teenage years, and they often remember it word for word,” she said. “It’s all about engaging people in the moment — but that moment can last the rest of the day for some people, and that’s important. It’s an easy activity if you can engage them.”

Added Vernon, “you see people light up when they hear their music. I think that’s an essential thing. That’s why most of our boxes have a CD with it. For the beach box, there’s beach-themed music. For the baby box, it’s lullabyes, softer music.”

Of course, she reiterated, the best boxes are the ones that engage all the senses. “It’s so worth the time and effort to make life better,” she said. “It works. We’ve validated it, and we know that it works.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections
Aging Population Creates Myriad Healthcare Challenges

Dr. Rebecca Starr

Dr. Rebecca Starr says the role of geriatricians and others who treat the elderly will become even more important as the over-65 population dramatically expands in the coming years.

It’s no secret that the nation’s demographics are skewing older. Paul Judd doesn’t think that’s all bad.

“People talk about aging of America, but it sure beats the alternative, which is not aging,” said Judd, vice president of Talent Acquisition and Workforce Planning for Baystate Health.

That said, the aging trend is no laughing matter for the healthcare industry, which faces a number of challenges directly related to the fact that Americans are living longer, often with multiple and chronic health conditions, than ever before, and the massive Baby Boom generation — all 75 million of them — will continue to swell the ranks of the over-65 crowd.

“In 2012, there were 40 million people over the age of 65. By 2040, it’s expected to double to 80 million. Really, that’s tremendous growth,” said Dr. Rebecca Starr, a geriatrician with Baystate Medical Center.

The cause isn’t solely generational; the fact is that modern medicine keeps sick people alive much longer than in decades past.

“We’re doing a great job treating heart disease, diabetes, COPD [chronic obstructive pulmonary disease],” she continued, “and as a result, people are getting through these very significant things that they didn’t used to survive, and people are growing older. And because they’re living longer, that means we’re seeing more dementia as well.”

All of that comes with a cost. In 2010, senior citizens accounted for 13% of the population but 34% of the heathcare costs, according to the Centers for Medicare & Medicaid Services. But national health expenditures are projected to grow at an average rate of 5.7% through 2023, and older Americans will drive the largest percentage of that cost.

At the same time, the role of geriatricians is expected to become more prominent, Starr said.

“We have extra training, we’re fellowship-trained, and we specialize in taking care of people over 65,” she explained. “Our goal is keeping people living independendly as long as possible, and healthy as well. We look at the whole person. We take a look at all their diseases and all their medications, and we make sure their medications are appropriate for them and don’t cause adverse side effects and also that we’re not treating the side effects of their other medications, what we call a prescribing cascade.”

That said, there’s a “tremendous shortage of geriatricians,” Starr said. “I think it’s pretty significant.”

In fact, many health fields may face shortages in the coming decade, because at the same time an older population is placing more demand on the industry — for both acute care and myriad services aimed at seniors’ health maintenance and quality of life — Boomers are aging out of the healthcare workforce as well, posing what could be a difficult recruiting landscape for health organizations large and small.

Age-old Concerns

It’s an issue Judd is deeply involved with, but Baystate isn’t waiting around for that coming wave of retirements.

“If there were a silver bullet, everyone would be doing it. It would be an easy fix, and it’s certainly not,” he told BusinessWest. “With the aging of the workforce, the approach we’ve taken is to truly understand where our aging is. So we’ve done a lot of workforce planning, to try to understand where we’ve got issues and what we need to do to fill these pipelines, if you will, well in advance of it becoming a problem.”

So Baystate has launched a number of workforce-development programs with area schools and colleges, and partnered with other health systems through the Regional Employment Board of Hampden County on worker-training initiatives.

“Instead of trying to steal from each other, we’re trying to take a look at the healthcare needs of the whole Pioneer Valley and say, ‘here’s what we all need; let’s create pipelines to fill all of our needs,’ instead of Baystate doing the training and everyone tries to steal them from us.

“We have to look at it from a community perspective,” Judd added. “You see we have all these healthcare offerings in the community, and they’re all important. From a community perspective, we’ve been somewhat successful at building some healthcare pipelines, working with places like HCC and STCC, developing programs and creating oppportunties for jobs. Some of the demand to do with aging, some with changing regulations with healthcare. We’re trying to get ahead of it, create these pipelines before it gets to where there’s an issue.”

Internally, Baystate has identified a number of areas where an aging workforce and other factors could come into play — operating-room nurses, for example.

“They can be a little difficult [to recruit], because a lot of nursing schools don’t have a rotation through the operating room anymore, as they did in past years,” Judd said. “Getting young nurses interested in going into the OR can be a bit of a challenge. So we created an internship, a nine-month orientation, for any registered nurses interested in going into the OR. That’s an issue I anticipate will become more acute over the next 10 years.”

Shortages are expected to be especially high in primary care, an issue that’s already rearing its head. In its most recent Physician Workforce Study, the Mass. Medical Society listed family medicine and internal medicine atop its list of specialties facing shortages already, and new recruits into primary care aren’t expected to match the anticipated retirements of older doctors.

Keeping the Pace

That’s one reason why keeping older people healthy has taken on a new importance in America — a reality that has seen the emergence of a number of programs to help families do just that.

Take, for example, Mercy Life, a PACE (Program of All-inclusive Care for the Elderly) program run by the Sisters of Providence Health System. Medicaid oversees PACE programs, which are on the rise in the U.S. because the role they play — providing a range of adult-day health programs aimed at keeping seniors out of nursing homes — is becoming more prominent.

Since Mercy Life opened its doors a year ago on the former Brightside for Children and Families campus in Holyoke, it has expanded its census to 82 seniors who come for primary care; physical, occupational, and speech therapy; and the services of a social worker, dietitian, nurse, and other care providers as needed.

“From anecdotal comments from people, the sense is that, in a really short period of time, people who come to the PACE program are experiencing an awakening of sorts,” said Chris McLaughlin, chief operating officer of the Mercy Continuing Care Network, which encompasses a number of independent-living, assisted-living, and skilled-nursing facilities, as well as home-care, hospice, and adult day programs.

He told of one man, about 60, who had been living with his father and never ventured out of his room. “He was kind of a curmudgeon. His brother-in-law said he reawakened when he came to the program. He didn’t think he’d like it — he wasn’t a social person — but he made friends, he’s smiling, he’s happy. His brother-in-law told me, ‘we’re seeing the old Bob we used to know come out.’”

Another woman whose husband was participating at Mercy Life told McLaughlin, “‘you’ve improved the quality of my husband’s life. He walks better, he’s not afraid he’s going to fall, and he’s regaining limited use of his hands via therapy and other work done with him.’

“People love the fact that their loved one can continue to live at home,” he continued. “We run some great nursing homes, but we never have anyone walk through the door and say, ‘geez, this is wonderful. I’ve always wanted to come here.’ They want to stay with their loved ones, in their own environment. And this has improved people’s vitality so they can continue living where they’re most comfortable.”

In a way, McLaughlin said, PACE programs are a form of accountable care, the model becoming more common at hospitals nationwide, which involve teams of providers being paid by insurers to keep patients well over a period of time, rather than being paid for each treatment, test, and hospital stay. It’s a model that becomes more challenging when dealing with an older population grappling with chronic conditions.

“As hospital stays decline, more care is being provided in people’s homes, where most of us prefer to receive care,” he told BusinessWest. “In a PACE program, we’re at risk for outcomes and at risk for managing seniors’ health within their means. The goal is to manage someone’s care and get them to a better state in terms of wellness and overall health.”

Hospital to Home

When she considers the aging of America, Starr recognizes a range of needs — specifically, growing demand for home care, residential care, adult day health, and various other services along the continuum for senior citizens. Part of her role is coordinating patient transitions into these various programs.

“That’s the goal, but it’s very difficult to put into place,” she said. “We have these multiple transitions of care; we have people transferred from one hospital to another for more acute care, they can go to rehab, perhaps home — that’s three or four transitions where you can have errors in medication, can lose track of follow-up … it can be a real problem.”

The key is communication between the different providers, especially at a time when the accountable-care model of healthcare is forcing hospitals to emphasize population health and reduce readmission rates — a task that becomes more challenging as the aging trend in America means more people living with chronic conditions.

“I think it obviously starts at home, and making sure that primary-care physicians have some geriatric training,” Starr said. “Then hospitals have to make sure the care of older adults meets the standard of geriatric care.

“Our goal is to keep people healthy by preventing and managing disease and helping people maintain function, the things they should be able to do — get out of bed, shower, get dressed, toilet themselves — because if that’s not maintained, that means extra care, that can mean nursing home as well.”

To better meet those goals, she explained, “one of the things we’re starting now is an acute-care floor dedicated to providing care for older adults, with the goal of maintaining function, preventing delirium, and having get them back home so they don’t need short-term rehab or, even worse, long-term care.”

It’s a model that might become more common over the next decade, she added. “It’s not as common as I think it should be, but where it’s been taken up, it’s shown things like reduced readmission rates, reduced length of stay, and reduced delirium. Getting people back home is really important.”

To do that effectively, Judd understands that hospitals and other providers need to be well-staffed, so he continues to cultivate programs to ensure a healthy future for Boomers in Western Mass.

“We’re taking a planning approach to it, getting in front of it, working with the local community colleges to build programs, and creating pipelines of people in the future,” he told BusinessWest. “I think, for communities like us, this will continue to be an issue.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections
Hospice Brings Quality of Life to Dying Patients, Families

Sarah Jackson, left, and Carol Lewis

Sarah Jackson, left, and Carol Lewis say the team aspect of hospice care is one of its most important features.

There’s a big difference, Leslie Hennessey said, between giving up on life and accepting that the end is near.

“Hospice simply gives people more support toward the end of life,” said the volunteer coordinator for Holyoke VNA & Hospice Life Care. “It’s not giving up; it’s changing the way we look at life. Do you want to go to your beach house one last time? Do you want to go see the Red Sox? We’re really focusing on quality of life, not how many days, weeks, or months you have left. The perspective changes; what’s really important to you? Because now is the time to do it.”

In short, families that choose hospice care for their dying loved ones “aren’t throwing their hands in the air. They’re saying, ‘this is what’s really important to us.’ A lot of times, that’s just spending time together as a family, saying the things they need to say.”

Most hospice programs follow the same format, Hennessey told BusinessWest. “The family and the patient generally meet with their physician about the diagnosis they have, and the physician has to certify that they have less than six months to live if the disease follows its normal prognosis. When we get the referral, we can admit them to hospice.”

It’s also a team approach to care. “Every patient gets a hospice nurse. They can also have a social worker if they’d like, a home health aide, or volunteer services if they choose. On top of that, we have other complementary services; we have a therapeutic heart program, a harpist to play at the bedside for the patient, and a pet therapist who visits patients in nursing facilities. I have a couple of volunteers who practice Reiki and energy work; we can offer that to patients as well.”

Carol Lewis, director of hospice at Spectrum Home Health and Hospice Care in Longmeadow, explained that “we’re looking for patients who have a terminal diagnosis that requires symptom management by nurses who have expertise in that area, and are educated in taking care of the holistic needs of that community. That’s the broad picture of what we do.”

She also stressed the team aspect of hospice care. “That’s the unique aspect of it; it’s a team of trained professionals that address these needs, and it’s not only about the patient, but supporting the family as well.”

For this issue’s focus on the business of aging, BusinessWest takes a look at an area of healthcare that has been growing in prominence as America’s 65+ demographic soars to record numbers — and the many ways hospice care is providing, if not hope for recovery, a measure of peace and acceptance for those approaching the very end of life.

Rising Tide

Indeed, 2009 saw 1,341,391 patients access hospice care; last year, that figure had risen to 1,542,737, a 15% increase.

There’s some statistical evidence that palliative, or comfort-only, care brings real benefits to the dying or critically ill. A study several years ago at Massachusetts General Hospital divided a group of stage 4 lung cancer patients into two groups; all of them received traditional chemotherapy through a physician, but half also enjoyed the services of a palliative care team.

The results, published in the New England Journal of Medicine, showed a measurable difference in the amount of anxiety and depression, while patients who had received palliative care from the start averaged a three-month survival advantage.

While some palliative care includes curative treatment, however, hospice is reserved for patients who forgo all but comfort-centered care; in other words, they’re no longer fighting to get better.

Sarah Jackson, executive vice president of Spectrum, explained that patients can receive hospice care in any community setting.

“Wherever you are, you can select a hospice benefit,” added Paula Boss, executive director of Holyoke VNA & Hospice Life Care. “At home, a nursing home, assisted living, a friend’s home — you can receive hospice care.”

At the heart of hospice care, Hennessey said, is a cadre of volunteers who spend time with the patient, particularly when their loved ones aren’t able to do so.

Leslie Hennessey, left, and Paula Boss

Leslie Hennessey, left, and Paula Boss say hospice services are available to patients wherever they live, whether at home or in a community care setting.

“They can’t provide any personal care or give medications, but they can be a presence in the house, sitting vigil with hospice patients. When a hospice patient is considered to be in the last hours of their life, and especially in nursing homes, if the families are far away and traveling to get to the person, our volunteers will sit with them until their loved ones get there. Families don’t want their loved ones to be alone.”

She said Holyoke’s volunteers hail from all walks of life. “A lot of folks have had experience with hospice in the past and loved ones in a hospice program, and they felt like they wanted to give something back; they realized how important it was, that extra support, how much they appreciated it, and they want to do that for another family.”

Hennessey said she conducts trainings twice a year for people who want to help in this manner. “Sometimes they say, ‘I don’t know if I can do this, but I want to try.’ They’re very special people.”

After all, she noted, “if you’re a hospice volunteer, you have to understand that every patient will die. That’s what we tell them on the phone before we even send them the information packet; I need them to know that every person they meet will die, and I ask, ‘how do you feel about that?’ It’s something they really need to consider. They know what they’re getting into when they walk through that door. They’re amazing.”

Lewis said Spectrum’s program also offers the services of a harpist with a degree in thanatology, the study of death, as well as service dogs that provide comfort to patients and their families.

“We also have a chaplain as part of the team,” she said. “When I say holistic care, I mean we meet physical needs, emotional needs, and more. Sometimes the chaplain is looking at some life review with the patient and the meaning of life, providing some comfort, or maybe just some reading at the bedside.”

Whether it’s the nurse, social worker, home health aide, chaplain, or volunteer at the bedside — and families can call for help 24/7 — hospice care is just as much a benefit for the family as it is for the patient, Jackson said. “We can be helpful for families, giving the caregiver a little bit of respite, by sitting vigil with their loved ones, having a volunteer come in for an hour or two so the family can take a break.”

At the same time, Lewis said, hospice staff takes time to educate the family so they can provide more effective care when hospice workers and volunteers aren’t nearby. “That really helps in the grief process, to look back and know you helped provide the comfort.”

Typically, hospice care includes a full year of grief counseling for the family after the patient dies, Boss said. “Often, the grief really hits them after the funeral, and they have continuing needs.”

Setting the Record Straight

Lewis said families often have misconceptions about what it means to elect hospice care. For instance, “a lot of people think they can never go to the hospital. But any time they need a level of care that isn’t offered in hospice, an emergency situation where they might need short-term help, they can go to the hospital.”

Also, Boss noted, “some people think they don’t receive any medication anymore, but that’s not the case. Yes, we often discontinue medications that are not needed for comfort or pain. But some cancer patients receive chemotherapy if there’s a comfort purpose and not a treatment purpose. We’re very strong on keeping people comfortable.”

Hennessey told BusinessWest that hospice benefits are typically covered by Medicare and Medicaid, as well as most private payers. “It’s not always something you’re looking for in your benefit package when you sign up, but most insurances have a hospice benefit, and it can be a huge benefit to families.”

The question for those families is when to take that step and admit that quality of life is more important than fighting an uphill battle for recovery. The growing ranks of older Americans have made end-of-life care a hot topic these days, and a tricky one.

That’s because, while doctors can extend life, often by artificial means, to a greater degree than ever, that intervention is often prohibitively expensive, and the quality of that life often dubious. So, increasingly, patients, families, and caregivers face hard questions — not about whether doctors can add weeks, months, or years to the life of a dying patient, but about whether they should.

“Awareness of hospice has increased, but barriers are still there — a lot of cultural barriers,” Boss told BusinessWest. “Some cultures really don’t understand the hospice benefit; they don’t understand all the things we can bring to them. There’s still a long way to go. A large number of patients are eligible to benefit from hospice, but never elect it.”

Hennessey cited a statistic that about 21,000 patients receive hospice care annually in Massachusetts, about 40% of all deaths. “It’s a good number, but it would be great if it was all patients, or close to 80% of patients.”

She also noted that the median length of hospice care is only 23 days, which means patients and families are often opting for it much later than they’re eligible. “We’re working with doctors and facilities to identify folks who could really benefit from these programs,” she said. “The benefit is for a life expectancy of six months, but in 23 days, we’ve just got things arranged, and then, unfortunately, we lose the patient.”

Lewis agreed. “Unfortunately, some families wait until the very end to contact hospice, but we’re able to get involved six months before the end, when there’s time to develop relationships with the team and to provide quality of life while the person is still here.

“It’s a chicken-and-egg situation,” she added. “A lot of times, people call us at the end, so the community sees us coming at the end and think we’re heavily associated with the end of life. But it’s earlier in the process that hospice really has its true benefit.”

So hospice advocates continue to get the word out to doctors and the public.

“It’s not giving up hope, throwing your hands up, saying, ‘I can’t cure this,’” Hennessey said. “I want to put you in the hands of people who can manage your pain symptoms so you can get the best life you can out of your last months.’”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections
Emeritus of East Longmeadow Caters to Residents’ Requests

Philip Noto

Philip Noto says the Emeritus of East Longmeadow building was carefully designed to accommodate the needs of aging seniors.

Philip Noto says the difference between Emeritus of East Longmeadow and other local assisted-living facilities can be found in the details.

“It’s easy to get the big things right, but small things play a major role in the happiness of residents,” said the facility’s executive director, noting that this is the reason why he fought to get granite countertops and full-size refrigerators installed in every unit when the building was under construction.

“I had managed other assisted-living facilities and listened to complaints from residents who wanted to keep ice cream in their freezers, but couldn’t do so because of their size. It might sound like a small thing, but paying attention to small things is what sets us apart from other communities,” he told BusinessWest, adding that his insistence on granite countertops was based on the knowledge that many people who move into residential communities are leaving upscale homes and don’t want to downgrade their kitchens.

Nathan Grenon, regional director of sales and marketing, agrees that small measures make a significant difference, and says everyone employed at Emeritus does their best to cater to residents’ requests. He cited an example of a 97-year-old woman who had been a gourmet cook who told them she hoped their chef would make homemade cream of carrot soup.

“She told us she had requested it for five years in another facility, but it was never prepared,” Grenon said. “So, we introduced her to our cook, who made it exactly the way she wanted, and today it is the most popular soup on our menu.”

Noto and Grenon cited myriad other examples of resident suggestions that have led to change within the state-of-the art, two-story, 90,000-square-foot building that opened April 21 on 10 acres of land on Parker Street. “Emeritus is a 25-year-old company; we recently merged with Brookdale Senior Living, and we now have more than 1,150 properties across the country,” Noto said, adding that decades of feedback from seniors were incorporated into the design of the East Longmeadow facility.

The building is airy, spacious, and well-lit. Comfortable chairs surround a cozy gas fireplace near the entrance, where residents gather to socialize or take part in activities. There is also an expansive dining room with a cathedral ceiling, a library, several courtyards, a business area equipped with computers with large touchscreens, a private dining room that can be reserved for family functions, a café where residents can prepare foods they like or enjoy snacks throughout the day or evening, a game room, a movie theater that seats up to 20 people in full-size armchairs, and a plethora of other common living spaces.

“We have 71 assisted-living units and one of the largest, most expansive memory-care neighborhoods in Western Mass.,” said Grenon. “There is a nurse on duty from 8 a.m. to 11 p.m., and we offer physical therapy, occupational therapy, and speech therapy on site.”

In addition to enjoying a full roster of activities, many residents stroll daily on a quarter-mile pathway that circles the building. Benches are set along it so they can stop and relax, and many gravitate to an outdoor gas firepit that burns brightly during inclement weather. In fact, residents enjoy going outside so much that a number of activities scheduled to take place inside are now held outdoors in response to their feedback.

Changing the Landscape

Noto reiterated that seemingly small details, including the food choices on the menu and the daily activities, make a difference in how happy residents feel on a daily basis.

To ensure that staff members know what residents want, Emeritus holds three monthly meetings and invites everyone who resides in the building. One is focused on general suggestions to improve the facility, the second gives people an opportunity to suggest new foods they would like to see served in the dining room, and the third allows them to vote on activities they want to engage in, as well as destinations for day trips.

“This is their home, and we want to get their input so we can adjust our program to meet their needs,” Noto said. “Our residents have a voice. Their concerns are heard, and we change things that are important to them.”

Grenon concurred. “We want to make their experience here as pleasurable as possible.”

Indeed, many changes have been made as a result of the meetings, which range from creating an area in the dining room where male residents can eat together, to rearranging the furniture in a common area and game room.

“The residents wanted to move the poker table into a room of its own, so we did it,” Noto said.

Grenon added that new activities have also been instituted, such as a Bible-study club that meets every Thursday. “The idea came from residents who were interested in spiritual activities,” he noted.

Brittany Sheehan

Brittany Sheehan shows off a life station in the memory unit at Emeritus at East Longmeadow, designed to evoke memories in residents who have children.

The fact that Emeritus does not require people to buy into the facility and residents rent on a month-to-month basis also gives them peace of mind. And although there are scheduled meal times, residents who miss a meal can be served at any time in the dining room. In addition, each unit has its own thermostat, which allows people to adjust the heat or air conditioning to their personal comfort levels.

These factors, combined with the dedication of employees, have led to success, and although the facility has been open only eight months, 45 of the 71 assisted-living units are occupied. Residents range in age from 66 to 99, and the ratio of females to males is about 50-50.

The assisted-living units include one- and two-bedroom suites with one or two baths. Each one contains a microwave, a full-sized refrigerator, and several large closets with a lockbox. The bathrooms have spacious showers with heat lamps and no lips, reducing the risk of tripping. In addition, the transitions between carpeting and wood floors are very smooth, making it easy for people to move through the community.

But Noto said the way residents are treated trumps the beauty and functionality of the real estate, and added that every member of his staff is passionate about their job. “We have an extensive interview process for job candidates. Every employee needs to feel they make a difference in the lives of our residents every day.”

Enhanced Memory Unit

Space has also filled quickly in the Acres, the memory-care unit, and Grenon said having it within the building allows people to “age in place,” giving them the option to move into it if they need extra help or support.

In fact, having assisted-living units and a memory neighborhood under one roof is ideal for some couples, he noted, explaining that one resident who lives in an assisted-living suite visits her husband every day in the Acres, where they stroll down the wide hallways within the secure neighborhood.

The thought that went into the design of the building can be seen in the layout of the shared rooms in the Acres. Although they were built for two people to live in, the only thing they actually share is the bathroom, which is situated between their private suites. Each person has their own door that opens into their living space, and shadowboxes are stationed outside that families fill with photos or mementos to help their loved ones easily recognize their personal entranceway.

Again, Grenon said families appreciate the attention to detail that is part of the program as much as the enhanced real estate.

“An example of this is that, when staff check on the residents every hour throughout the night, they have to enter each person’s bathroom and press a button to signal that they have actually been there,” he noted, explaining that the signals are recorded, which alleviates any anxiety as to whether the hourly checks actually occur.

The Acres also contains unusual ‘life stations,’ designed to promote activities that are familiar to residents. One contains a crib filled with baby dolls, a changing table with doll clothing, and a rocking chair. “Many of our residents are mothers, and when they see the dolls, they pick them up, change them, rock them, and even bring them to meals,” Grenon said.

Another life station contains a map and globe and was created to spark memories about places residents have visited, while a third has a collection of men’s and women’s hats, scarves, and jewelry they can don at a dressing table with a mirror.

“The life stations are part of our effort to keep them engaged and keep their brains stimulated. We don’t want people staying in their rooms,” Grenon said.

A special ‘quiet room’ was also built into the unit. It doesn’t have windows and is used by staff members as a place to bring residents who are agitated or suffering from the confusion that can occur when the sun sets. “They can turn on relaxing music and calm the person down in this quiet, secure place,” he explained.

Memory Care Director Brittany Sheehan says caretakers in the Acres are trained in how to deal with memory loss, and get to know each resident well. She added that the caregivers serve the residents’ meals and help them with daily tasks of living, such as dressing and showering, which allows them to build solid relationships through continuity and familiarity.

“It also helps them learn what each resident likes and dislikes,” Sheehan said. “But before they even move in, I have their families fill out a detailed, six-page questionnaire so we can provide personal touches they would have enjoyed at home. For example, a resident might like a cup of tea every night before going to bed. We do our best to customize our care to fit each individual’s needs.”

She runs a monthly support group for families and meets with them on a regular basis. “I call them if their loved one is having a bad day or a really good day. And every month I mail them ‘A Moment in Time,’” she said, explaining that it is a handwritten letter with pictures of their loved one engaged in activities.

Quality of Life

Grenon said Emeritus has quickly become a valuable community asset.

“Before it was built, many people were apprehensive because they didn’t know what to expect,” he explained. “But officials in East Longmeadow and people in the surrounding towns have been very supportive since we opened, as they appreciate what we have to offer.”

Noto agreed, and said the facility’s staff will continue to focus on improving small things that make a difference.

“Our residents have a voice, and we change things in response to their requests,” he said. “Everything we do is aimed at providing quality care, which is important because this is their home.”

Business of Aging Sections
Things to Know When Your Child Is Also Your Caregiver


It is very common for a child to provide care to an aging parent in order to allow the parent to continue to live at home. A child is most commonly the caregiver because the parent will not agree to hire professionals to assist with the activities of daily life. Typically, the parent has concerns regarding privacy, and their child is the only caregiver they will trust.

Gina Barry

By Gina M. Barry, Esq.

When a child provides care to a parent, it is best to establish a care agreement. A care agreement is a contract that outlines the care to be provided, as well as any payment to be made for that care. The care is typically provided until the parent passes away or is in need of care that cannot be provided at home. Tasks performed by the child usually include personal-care assistance, grocery shopping, meal preparation, accounting services, transportation to and from appointments, housecleaning, and laundry services. It is recommended that the care be paid for on an ongoing basis as the care is actually provided.

The care agreement should set forth the exact services that the child will provide, as well as the location where the services will be provided. The parent’s ‘space,’ as well as any ‘common areas,’ should be detailed. Additionally, the agreement should set forth whether the parent or the child is responsible for paying monthly utility charges, as well as yearly expenses, such as property taxes and homeowner’s insurance. The agreement should also address responsibility for property maintenance, such as needed repairs, mowing the lawn, additional landscaping, and snow removal.

It is crucial to value the services to be provided in the care agreement. Services may be valued as a package or individually. The package rate is useful when the care provided is substantially similar to that of a facility, such as an assisted-living facility or nursing home.

When using the individual pricing method, the child must keep a record of the services performed and receive payment based on the actual amount of service provided. All payments to the child are taxable income to the child and should be reported on the child’s personal income-tax return. In this regard, it is also important to realize that most caregiving children will find their availability to work outside the home greatly reduced or eliminated.

The parent and child should also set forth the circumstances under which the child is willing to provide care for the parent and the terms upon which the agreement may be cancelled. In order to avoid the appearance of an illusory promise on the child’s behalf, the agreement should provide that cancellation will occur only upon the occurrence of specified conditions — for example, if it becomes unsafe to continue to provide care in the home. The agreement should also allow for written amendments, so that the agreement can be changed if the situation changes.

The impact of a care agreement with respect to the parent’s options for financing nursing-home care is substantial. Currently, nursing-home care costs approximately $13,000 per month and is most commonly paid for by accessing long-term-care insurance, privately paying, or obtaining MassHealth benefits.

When applying for MassHealth benefits, MassHealth will ask whether the applicant has made any gifts in the last five years. If gifts are found, MassHealth will assess a penalty that prevents the applicant from obtaining benefits for a certain time period based on the amount of the gift. When assets are transferred to a child as payment for care provided, it may be possible to avoid this penalty, as the money was transferred to pay for the services provided and was not a gift.

It should be noted that caregiver agreements are subject to intense scrutiny by MassHealth. If a MassHealth application is anticipated in the future, the care agreement must be carefully drafted and must take into account MassHealth’s current position as to these agreements.

Although there are many issues to address when establishing a care agreement, outlining the responsibilities of both the child and the parent will prevent most disagreements, as the agreement will lay the framework for success. A successful care agreement will allow the parent to remain at home much longer. In addition, a properly drafted care agreement can be financially beneficial to both the parent and the child. As such, the benefit of having such an agreement in place far outweighs the effort involved in establishing the agreement.

Gina M. Barry is a partner with the law firm Bacon Wilson, P.C. She is a member of the National Assoc. of Elder Law Attorneys, the Estate Planning Council, and the Western Mass. Elder Care Professionals Assoc. She concentrates her practice in estate and asset-protection planning, probate administration and litigation, guardianships, conservatorships, and residential real estate; (413) 781-0560; [email protected]

Business of Aging Sections
Why You Need to Plan for the End


Physicians undergo years of education and training to promote wellness, cure and heal, and protect life. Yet, we also know that death is inevitable, and we are increasingly recognizing the importance of advance care planning. We urge patients to do the same.

Advance care planning is the term for the planning we do as our healthcare becomes complicated and we need to make challenging decisions about our care, often toward the end of life. Planning becomes an integral part of most people’s lives at an early age, and most of us are always planning ahead. We plan for education and careers; we create wills, buy life insurance, and establish retirement accounts.

Advance care planning can be thought of in the same way, as a medical part of the future, because one day, despite how intense our will to live may be, the end will arrive. Planning makes your wishes known ahead of time and ensures that they are fulfilled.

The planning begins with the simple act of talking with your healthcare provider and family members to let them know what your wishes are about end-of-life issues. Once those decisions are reached — and it can be appropriate over time to revisit the discussion to change or refine previous decisions — patients then complete certain forms to specify their wishes.

Two of the most important forms are the healthcare proxy and a MOLST form. A healthcare proxy indicates which person you choose to make healthcare decisions on your behalf should you become unable to do so. The MOLST form — an acronym for medical orders for life-sustaining treatment — outlines your preferences for such areas as whether or not you wish to be resuscitated in certain situations. Copies of completed forms should be distributed to family members and all your healthcare providers.

Advance care planning isn’t recommended just for elderly patients or those with terminal illnesses. Physicians recommend that the conversation and planning for everyone start earlier rather than later because of the uncertainty of when that final moment might arrive.

End-of-life care may also include palliative care and hospice care, and patients are urged to learn about these areas of medical care as well. Palliative care refers to the type of care that is delivered when someone is diagnosed with a life-limiting illness. Hospice care is care for those entering the last few months of life, usually with a prognosis of six months or fewer to live.

Getting the conversation started is the first step, and getting it started early is important. Not only will that make your wishes known, but it has benefits for family members as well. Letting your family know what you want in these serious circumstances can prevent your loved ones from carrying the burden of deciding your course of care. It may also avoid family turmoil, as each family member knows exactly what your wishes are and how they are to be carried out.

Healthcare can get more complicated as we age. We may accumulate more illnesses, get frailer, and become more susceptible to injury. Advance care planning makes us think about what we want, what’s most important, and then communicate that with family members and the healthcare team.

Physicians certainly recognize the persistent hope patients can have, even in the most dire of circumstances. But in addition to being a healthcare advocate throughout life, physicians are now able to play an important role in end-of-life care as well.

Many patients who face terminal illness tell us that they are praying for a miracle. We believe in miracles, too: the miracles of dignity, comfort, love, and peace. If patients work together with their healthcare team, physicians can help to make those miracles happen.

If you or a family member wants to talk, and your healthcare provider doesn’t open the conversation, we urge you to take the first step and ask. The topic is too important to ignore.

More information, including a free brochure, Planning Ahead: What Are Your Choices? which lists a number of resources, is available free from the Mass. Medical Society at www.massmed.org/advancecareplanning. For a video discussion, visit www.physicianfocus.org/advancecareplanning.

Dr. Eric Reines is a geriatrician with Element Care in Lynn, and Dr. Beth Warner is a geriatrician with Cooley Dickinson Health Care in Northampton. Reines is chair, and Warner is a member, of the Mass. Medical Society’s Committee on Geriatric Medicine. This article is a service of the Mass. Medical Society.

Business of Aging Sections
Cardiac Rehabilitation Helps Patients Get Their Lives Back

Patrick Schilling

Patrick Schilling, right, says Cooley Dickinson’s cardiac rehab program has helped Dennis Vandal recover from heart surgery.

After Cindy Mahoney suffered a heart attack early in 2013 — an event attributed to a rare condition called spontaneous coronary artery dissection — she was treated at Cooley Dickinson Hospital and, several weeks later, was taking the right medications and otherwise felt fine.

But she’s a runner at heart (no pun indended), and had run about 30 minutes a day for the past 35 years, and worried about how much exertion she could handle — and whether another heart attack would occur if she pushed herself too hard or soon.

However, after entering a cardiac rehabilitation program at CDH and exercising, twice a week for two months, under the supervision of cardiac exercise physiologist Patrick Schilling and two cardiac nurses, Mahoney set aside her anxiety, convinced she could get back to what she loved doing.

“The entire rehab experience was hugely reassuring to me and my family,” said Mahoney, who finished two 5K races in the months after completing the program. “The cardiac-rehab program helped me realize I could do what I love again — safely.”

That confidence boost, Schilling said, is one of the major benefits of cardiac rehabilitation, a customized program of exercise, education, and support designed to help individuals recover from a heart attack, cardiac disease, or heart surgery.

“There’s a lot of anxiety. They’re wondering, is this going to happen again? It’s so fresh in their minds, how they felt when they were getting treatment a few weeks ago,” he said. “We can help rebuild their confidence, not only about how well they’re going to do, but their ability to take control of their lifestyle.”

According to the Mayo Clinic, cardiac rehabilitation is typically recommended for patients who have experienced a heart attack, coronary artery disease, heart failure, peripheral arterial disease, angina, cardiomyopathy, certain congenital heart diseases, coronary artery bypass surgery, angioplasty and stents, heart transplants, and heart valve replacements.

“The benefits of a cardiac-rehab program have been nationally proven,” not just in its initial benefits, but in patients’ long-term compliance with taking recommended medications, changing an unhealthy diet, and controlling issues like diabetes and high cholesterol, said Elaine McCaffrey, a nurse clinician in Baystate Medical Center’s Cardiac Rehabilitation and Wellness Program.

That’s not surprising, she added, considering how much of a wake-up call a heart attack or heart surgery can be.

“There’s so much folklore around the heart, a lot of religion centers on the heart — people have a lot of different feelings when it comes to the heart,” she noted. “So a major surgery or major event like this does lead to some anxiety — ‘how can I get back to what I really want to do in life?’ That’s where cardiac rehab comes in.”

Four-pronged Approach

Cardiac rehabilitation — which is covered by virtually all health insurance when a patient is referred by a primary-care doctor or cardiologist — is comprised of four main components:

Medical evaluation. The rehab team — which might include a cardiologist, nurse educator, dietitian, exercise rehabilitation specialist, physical or occupational therapist, and psychologist — will assess a patient’s physical abilities, medical limitations, and risk factors for heart disease, stroke, high blood pressure, and other conditions. They will also continue to track the patient’s progress over time, along the way tailoring a safe, individualized rehabilitation program.

Elaine McCaffrey

Elaine McCaffrey says the exercise, education, and support components of cardiac rehab are all important in helping patients reclaim their lives.

“The program is designed in such a way that it helps the patient reduce fatigue and improve energy levels,” Schilling said.

Physical activity. Cardiac rehabilitation improves a patient’s cardiovascular fitness through walking, cycling, rowing, jogging, strength training, and other activities.

“Many activities we do in the gym are cardiovascular in nature, but it also includes strength training. We use treadmills, walking bicycles, a rowing machine, upper-body exercises,” Schilling said, noting that this component of cardiac rehab is a relatively recent development. “Heart recovery is fairly slow, and 30 years ago, patients were put on bed rest.”

The Mayo Clinic recommends supervised exercise three to five times a week, adding that it’s important to teach proper techniques, including warming up, stretching, and cooling down.

Lifestyle education. This may include guidance on everything from managing pain and fatigue to making healthier food choices aimed at reducing fat, sodium, and cholesterol; from understanding medications to getting back to sexual activity.

“There’s definitely an educational component to it,” McCaffrey said. “They don’t leave cardiac rehab without knowing what they need to do to stay heart-healthy. When we talk about the risk factors for diabetes, high blood pressure, hypertension, these are things that can be controlled. We talk about a healthy diet, monitoring blood glucose to keep diabetes under control, exercise, and getting to a heart-healthy weight.”

Of course, the number-one risk factor for coronary disease is smoking, so when a patient is a smoker, programs educate them about the dangers and develop strategies for quitting. “They need to make that big social change — for themselves and the rest of their family,” she said.

Support. Depression and anxiety are natural reactions to a major heart event, which is why cardiac-rehab programs stress the emotional and social components of recovery as well as the physical and educational aspects. These might include anything from counseling to occupational therapy to help patients return to work.

“We get you to understand what you need to do to take control of your life, and make it a very beneficial, productive life,” McCaffrey said. “And the whole time, you have companionship; you’re meeting people who are going through it with you.”

Schilling agreed. “Rehabilitation rebuilds confidence, so they realize it’s not a sentence, but something they can live with,” he said. “You really see their improvement, and see their confidence go up.”

Full Speed Ahead

Schilling was quick to add that recovery from a cardiac event — particularly in the case of a heart attack or stroke — begins with the emergency response as it’s happening.

“The gold standard from onset of symptoms to the cardiac catheterization lab is 60 minutes,” he noted. “Time is definitely the enemy in this case; the quicker a person gets treatment, the more heart function gets preserved.”

But once the initial crisis has passed, a team springs into action to help patients fully recover for the long term. McCaffrey and Schilling both came back repeatedly to the phrase ‘activities of daily living,’ emphasizing that the goal isn’t for patients to return to a life that’s a shell of what it was before their sickness or surgery, but, rather, resume the same lifestyle they enjoyed before.

“We have patients ranging in age from 24 to 90,” McCaffrey said. “So we need to know, what are your activities of daily living? Is it returning to a job? Is it being a mother to your young children? Or, if you’re a little bit older, is it just living as healthy as you can?”

Of course, some patients want to return to a high-stress career, and others want to get back to playing sports or, like Mahoney, running every day. No matter what the goal, McCaffrey said, it’s the rehab staff’s responsibility to tailor the program to the goals and needs of each individual patient.

“Cardiac rehab is for anybody and everybody,” she said. “It really does help with recovery, and that’s the key; that’s the whole purpose — that feeling of confidence that they can get on with their life.”

Schilling agreed. “It’s gratifying to work in cardiac rehab. We definitely do it with the onus of wanting to help people. It’s a real passion for me and my co-workers,” he said, adding that he’s amazed at how different patients look at the start and end of rehab — not just the condition of the bodies, but the level of confidence on their faces.

He’s grateful, in short, to be doing life-changing work. “I’ve been here eight years, and I’ve never had a boring day.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections
Armbrook Village Helps Seniors Navigate Stages of Life


Executive Director Beth Cardillo

Executive Director Beth Cardillo

In the sleepy northwest corner of Westfield lies a winding path marked by a sign that reads “Armbrook Village: A Senior Living Residence.” But that description only tells part of the story.

This modern, 109,000-square-foot structure, which looks like a recently finished condominium complex with its siding, flowerbeds, and bleach-white balconies, is part of a growing wave of senior-living communities that offers older citizens a variety of options along the continuum of aging, its 122 units encompassing independent living, assisted living, and what’s known as Compass Memory Support Neighborhood, which allows residents with memory loss to receive constant treatment and supervision in a secure setting.

The result is an interactive community in the best sense of the word, said Beth Cardillo, executive director.

“We’re not going to get any bigger; we were built to operate at a very manageable size,” she told BusinessWest, adding that the facility, which serves seniors from age 60 to 100, is nearly three-quarters full. “We know everyone in the building. We know everybody’s daughter and son, we know everybody’s grandkids, and we work hard to provide a community atmosphere.”

Armbrook Village was built by East Longmeadow developer Michael McCarthy, along with other investors, in 2012 after he saw the benefits his late mother, Jean, experienced at a senior-living residence in Springfield. However, without any background in elder care or independent-living arrangements, he hired Senior Living Residences (SLR) — a Boston-based company specializing in senior housing operations with a special emphasis on dementia and Alzheimer’s disease — to manage the facility.

Managing 12 communities from Boston to Milford, SLR is affiliated with Boston University’s Alzheimer’s Disease Center, and seven of the chain’s communities feature Compass Memory Support Neighborhoods. With most of the residences located in Eastern Mass., Armbrook Village is the only SLR community on the Bay State’s western region, but it operates with the same goal as all the company’s properties — providing cost-effective care to all residents, whether they’re living independently and going to work each day or need assistance getting up in the morning.

Modern Living

For those living in the studio, one-bedroom, or two-bedroom apartments, Armbrook provides perks that allow residents to be totally on their own, “but not completely,” Cardillo said. Those perks include services ranging from emergency pull cords in each unit to transportation to doctor’s appointments.

The facility also makes it a point of encouraging its residents to get out into the community by providing transportation to restaurants, symphonies, and museums, among other destinations throughout the year. Independent-living residents also have access to three meals a day, prepared with an emphasis on ‘brain-healthy’ foods, as part of Armbrook’s affiliation with BU’s Alzheimer’s Disease Center.

According to Cardillo, SLR emphasizes such a diet throughout its communities, with a number of menu items built around a Mediterranean diet of fish, whole grains, and other foods that are both nutrient-rich and contain omega-3 fatty acids, a fat believed to help reduce the risks of dementia.

“Our statistics show it’s good for the brain,” she said. “A lot of olive oil, a lot of vegetables, a lot of fish, a lot of chicken — all studies point to certain herbs and foods not curing dementia, but adding to the mix of prevention.”

Independent-living residents enjoy other amenities as well, with apartments equipped with kitchens, washers and dryers, and walk-in showers. The apartments are designed to be “desirable,” said Cardillo, breaking away from the past industry standard of small, converted rooms.

Armbrook-Village “Years ago, I think, when assisted living became popular, they were taking the place of older buildings, maybe a converted school, a converted monastery. So the rooms were a lot smaller,” she told BusinessWest. “But now, when families are starting to look for apartments for their elders, they’re thinking, ‘just because Mom is 90 doesn’t mean she has to live in a small apartment.’”

Meanwhile, assisted-living residents receive help with many activities of daily living. Among those services are assistance with getting up in the morning, showering, getting dressed, as well as help with taking medication. Three meals a day are provided.

“Our assisted living is almost the same, only a little bit smaller, because they don’t need a full kitchen because we’re supplying the meals,” she explained.

Then there’s the Compass Memory Support Neighborhood, which features everything found in assisted living, plus some additional services. A smaller neighborhood with 25 units, it’s “the world in a smaller place” for residents with certain memory-related disorders, Cardillo said. “It’s a world that’s easier to negotiate, and it’s filled with activities all day long.”

The rooms were designed to be compact, she continued, since a number of residents there have a hard time finding their way around in bigger spaces. At the same time, the neighborhood’s activity rooms were designed to be larger, allowing residents to conduct activities and ensure that they are not isolating themselves in their own rooms, but staying involved in the community.

“We know that, with dementia, structure and socialization are key,” Cardillo said. Part of that socialization includes bringing out residents for art, photography, and adult learning activities, said Brenda Lopes, director of the Compass Memory Support Neighborhood.

“Here at Armbrook, we do a lot of adult learning, including a program called Reconnections,” Lopes said. “In it, we bring the memory-support residents back into the past with, say, imagery of Frank Sinatra and the Rat Pack or from World War II, and it works to help them connect the past with the future.”

That, along with a number of individualized programs and daily exercise, are among the routines that not only keep the residents active but also work against the effects of dementia and Alzheimer’s.

To enhance their care of residents, SLR involves staff in joint training operations through Boston University and, in Armbrook’s case, participation in a graduate study program with American International College’s occupational-therapy students. Part of a research project conducted by the students, the goal is to have residents in the Memory Care wing increase their daily activities through interacting with music as the AIC students observe its effectiveness and results.

Making Westfield Dementia-friendly

As part of its efforts to improve life for people with memory issues, Armbrook has launched a campaign to make Westfield one of the first ‘dementia-friendly’ communities on the East Coast.

Specifically, inspired by the story of Watertown, Wis. and its own drive to make the town friendlier and safer to those who are experiencing dementia, Cardillo set out earlier this year to coordinate with businesses and departments across Westfield to create an environment where, if an individual with memory loss were to wander into a restaurant or other establishment, staff would know the right steps to handle the situation.

“We’re trying to have more people learn more about dementia, so that, say, if an 85-year-old woman walks into the bank and is very confused, the tellers will be able to know what to do, properly identifying any confusion or memory issues,” Cardillo said. “I would like to do trainings throughout the community and here at Armbrook to teach people a little more about dementia, so that they can embrace it and not be scared by it and have the resources to know what to do.”

In addition to local banks, grocery stores, and other places of business, Cardillo wants to include the city’s police and fire officials, who sometimes find themselves dealing with people, either on the phone or at a scene, with some form of memory loss.

Already, a “virtual dementia tour” has begun involving the Fire Department, said Cardillo, a short (10-15 minutes) explanation of the symptoms of dementia. Hoping to include Noble Hospital and the local senior center, among other organizations, she plans to produce a PowerPoint in the near future as she continues to meet with officials such as the mayor and Chamber of Commerce.

“It’s about giving people the tools they need in order to know what to do when they come across somebody with dementia,” she said — tools her team at Armbrook Village provide to residents every day.

Business of Aging Sections
This Growing Model Bridges Gap Between Primary, Emergency Care

Rick Crews, left, with partner Jim Brennan

Rick Crews, left, with partner Jim Brennan, says there are many reasons — from affordability to its ability to save individuals time and aggravation — why urgent care has become so popular.

Rick Crews has been heralding the benefits of urgent care since he and Jim Brennan opened their first afc Doctors Express practice five years ago.

“We’re treating many people who traditionally used to go to the ER — but a lot of that was not appropriate,” he said of patients whose illness or injury didn’t rise to the level of an emergency, yet had no access to primary care.

“This is an alternative — a place you can go with really high-quality care that’s much more affordable, and get that care in a more timely fashion. That’s why urgent care is so successful right now.

“Hospitals need to concentrate on doing what they do best — the sicker patients, the more labor-intensive patients,” he continued, adding that patients who crowd the ER with less pressing matters cause a backlog, which elevates waiting times and frustration levels for everyone. Several area hospitals have recently renovated and expanded their emergency departments, but Crews said that’s not always the answer.

“I think we’ve provided relief for the hospital so they don’t have to build a new facility, and we’ve provided an outlet for patients, who can be seen for something in a much quicker fashion.”

If it sounds like hospitals consider afc Doctors Express and other urgent-care facilities a competitive threat, think again. In fact, hospitals are increasingly opening urgent-care clinics of their own to provide a level of care between the doctor’s office and the ER, with hours that often extend well into evenings and weekends, unlike the typical primary-care practice.

In some cases, hospitals are even teaming up with urgent-care practices, as evidenced by the recently announced affiliation between Boston-area afc Doctors Express franchises and Steward Health Care, a network of 11 hospitals and other facilities.

“The way our affiliation is set up is really cool,” Crews told BusinessWest. “When a patient walks in the door, we ask them, ‘do you have a primary-care provider?’ If they say ‘no’, we will refer them to primary-care physicians with the Steward group. And their family-practice physicians will refer their patients to afc Doctors Express after hours and weekends for urgent-care needs.”

Through the affiliation, 45 family-practice, emergency-medicine, and internal-medicine physicians employed by afc Doctors Express will join the Steward Health Care Network, and afc Doctors Express physicians will have access to Steward’s patient portal to evaluate a patient’s clinical history prior to commencing treatment. Clinical notes from an urgent-care visit will be communicated back to a patient’s primary-care physician or specialist for necessary follow-up.

“The hospitals are embracing urgent care; they see it as a great thing,” said Dr. Richard Freniere, co-owner, Urgent Care of Wilbraham, which opened last year. “We really have some good relationships with both Baystate and Mercy, open communications with doctors and emergency rooms in both hospitals.”

The pair know something about hospital ERs, since they’re both employees in the Wing Memorial Hospital Emergeny Department in Palmer, although Freniere devotes the bulk of his time these days to the Wilbraham facility.

“Baystate opened up an urgent care; they see the value of it,” Freniere said, citing just one of the area’s hospital-affiliated practices. “But we’re starting to see other competition coming in — little mom-and-pops, with one doctor, taking a shot at urgent care.”

Growing Model

According to the New York Times, the proliferation of those tiny practices makes it difficult to determine the exact number of urgent-care facilities in operation, but the Urgent Care Assoc. of America pegs the figure at around 9,000 — and growing.

Dr. Ateev Mehotra, associate professor of Health Care Policy at Harvard Medical School, told the newspaper that greater patient awareness of urgent care is causing a cultural shift.

“We expect to do our banking 24 hours a day, seven days a week, and to shop 24/7,” he said. “So now we want our healthcare to be 24/7.”

The cost of urgent care, with its much lower co-pays than emergency care, also appeals to patients — not to mention commercial insurers. By any measure, Freniere said, Wilbraham Urgent Care has been a success.

“We definitely way exceeded our one-year expectation. We are basically at our max volume right now. For the size of the facility we have, I really don’t want to burden the system any more than we do. If we go much more than this, we’ll have what happened in hospitals, getting too many people, and we won’t be able to provide what we set out to do in the first place.”

And seeing patients quickly is a hallmark of urgent-care clinics, with wait times typically averaging a half-hour or less, compared with several hours at some hospital ERs. So is time flexibility; according to the American Academy of Urgent Care Medicine (AAUCM), only 29% of primary-care doctors offer after-hours coverage, but urgent-care practices are generally open evenings and weekends, with some offering around-the-clock care.

Dr. Richard Freniere

Dr. Richard Freniere says hospitals are embracing urgent care, rather than viewing it as a threat, because it enables them to focus on what they do best.

That’s a relief for patients who would rather not deal with the emergency room to have a minor injury or illness treated. According to the AAUCM, the number of emergency-room visits increased by more than 1 million per year between 1994 and 2004, while the number of hospitals and ERs decreased by 9%.

Today, emergency departments handle 110 visits annually, and many are clearly not emergencies. A 2009 RAND Corp. study reported that up to 27% of ER visits could be easily handled by urgent-care centers or retail clinics, saving up to $4.4 billion per year in health costs.

“We’ve all experienced the five-hour wait at the ER — it’s not good,” Crews said. “We’ve all experienced those long waits and frustration in crowded ERs, so we are providing an alternative.” In fact, across the four practices he and Brennan own and six others for which they are master franchisees, patients’ average door-to-door time last year was 49 minutes.

“That’s a huge differentiator,” Crews said. “Then there’s the cost — in the emergency room, the average deductible is $100 to $200.”

Freniere agreed. “Being ER doctors for the past 20 years, we’ve seen all the people coming in and getting frustrated at times. And many of them really don’t need to be coming into the emergency department and incurring a high cost of care.”

The fact that a successful urgent-care practice can be very profitable isn’t lost on private-equity funds, which have purchased many urgent-care networks over the past few years. Insurance companies have also gotten into the ownership game. “Clearly there’s more competition now,” Freniere said.

Still, the Wilbraham practice has been such a success that the partners are preparing to open a second location in Worcester County. “And I’m not sure that’ll be the last place we do.”

Catching On

Massachusetts is especially fertile ground for urgent care, said Freniere, because the Bay State lagged considerably behind much of the country in adopting the urgent-care model, although that’s clearly changing.

“I think Massachusetts is a little late to the game,” he told BusinessWest. “We’re advanced in high-end care, but we really took the slow approach to urgent care. Everything was done in the hospital; everything was done in the big medical center. It never felt as if we had to cater to the patient. I think that’s a big change.”

That change includes the attitude of hospitals, which increasingly see the value in this relatively recent model. “They’re saying, ‘hey, guys, we want to get you to work with us. You’re complementary to what we’re doing.

“Doctors are coming around too,” Freniere added. “Initially they saw us as competition, but now they see us as supplemental. We’re not out to take anyone’s patients from them. We’re helping to unburden the system, basically.”

Crews has seen that shift as well. “There’s been a lot of change over the past four or five years since Jim and I opened up our first one,” he said. On the national level, afc Doctors Express — which was recently purchased by American Family Care — will boast more than 160 sites by year end, and Crews and Brennan expect to increase their total from 10 to 18 by the end of 2015.

“We continue to grow every year as patient volumes increase,” Crews said. “It’s because we focus on providing an exceptional patient experience, great quality medical care, convenient hours, and low prices — all those things together.”

Since affiliating with Steward, he said the partners have been busy meeting with the system’s hospital presidents and talking strategy. “These hospitals out there are embracing us.”

As for Freniere, he said he has been contacted by a large urgent-care company, but has no plans to sell — in large part because he finds delivering healthcare in this way a gratifying experience.

“The way the model is set up, the way it’s working right now … it’s attracting attention,” he said. “I think it’s the future.”

Joseph Bednar can be reached at [email protected]

Business of Aging Sections
Fallon’s Summit ElderCare Sets a New Standard

Pam White and her mother, Helese

Pam White and her mother, Helese, in the library at Summit ElderCare in Springfield.

Pam White is an only child, and is still many years from being in a position to retire.

Which means that she faces some significant challenges in her role as caregiver for her mother, Helese, who has several health issues, but is neither ready nor willing to move into a nursing home.

Pam told BusinessWest that, as she launched a search for a solution to her dilemma, she did so with a specific mindset. She was looking for a facility that was a step above adult day care and two or three steps above a community senior center — a place where medical care was available in the form of an on-site geriatrician, but where there was also a strong social component with a host of activities for a diverse group of seniors.

She has found all this and a lot more at Summit ElderCare, a PACE (Program of All-inclusive Care for the Elderly) facility operated by Fallon Community Health Plan in Springfield’s North Medical District.

The facility, which opened its doors roughly a year ago, now serves 53 individuals with roughly the same needs as Helese. They are called ‘participants,’ rather than ‘clients,’ ‘patients,’ or ‘customers,’ because that term best describes what they are, said Kristine Bostek, vice president and executive director of Summit ElderCare.

Elaborating, she said they are participating in a program, based on a national model of coverage recognized by both Medicare and Medicaid, that provides medical care, geriatric case management, care coordination, adult day health services, full insurance coverage (including Medicare Part D prescription coverage), and in-home support in a personalized setting that features interaction with other seniors and a host of activities.

All of this resonated with Pam White.

“My mother is a very social person, and what appealed to me is that there would be other seniors involved in this program,” said White. “I wanted to engage my mother in a program where they have activities, and where it’s obviously a safe environment.

“It’s like one-stop shopping,” she went on, referring to the range of services offered at the facility. “They have a primary-care physician that specializes in geriatrics, and if my mother needs lab work, that can be done. And if I were trying to do that as caregiver, I’d be running here and running there, and that’s difficult with my work schedule.”

Kristine Bostek

Kristine Bostek says Summit ElderCare calls those it serves ‘participants’ — rather than clients, patients, or customers — because that word best reflects what they are.

The Springfield location is one of five now operated by Summit ElderCare in Central and Western Mass., said Bostek, adding that the company started with a location in Worcester in 1995 and eventually added a second facility in that city before eventually expanding into Charlton and Leominster. Further expansion into the Merrimack Valley is now under consideration.

An assessment of the Western Mass. market several years ago revealed a need for a PACE facility there, said Bostek, noting that, after consideration of several possible landing spots, the company eventually chose a location in Springfield in a new medical building on Wason Avenue built to Fallon’s specifications.

One year after opening that site, the company is on target with regard to growth, said Mary Woodis, RN and site director, adding that this location will likely hit its goal of 250 participants within three years.

For this issue and its focus on the business of aging, BusinessWest takes an in-depth look at Summit ElderCare’s Springfield facility and how it is improving the quality of life for both participants and their caregivers.

Senior Moments

Bostek told BusinessWest that the PACE concept is gaining considerable traction across the country, with more than 100 sites currently operating nationwide.

Fallon is now the fifth-largest PACE provider in the nation, with 900 total participants, and the largest in New England, she said, adding that the company is a firm believer in this model of healthcare because it provides a viable option to more expensive nursing-home care, and will only become more popular as the population ages because of the many benefits it provides for people like Helese — and the peace of mind it offers to those like her daughter Pam.

The concept was described by both Bostek and Woodis as a “community-based alternative to nursing-home care,” and one with two critical elements: a healthcare component and a social component, which are both considered critical in the delivery of complete care to a participant.

Elaborating, Woodis said Summit ElderCare provides geriatric case management, care coordination, and a host of additional services that include:

• On-site medical care;
• 24/7 emergency access to a staff member;
• Physical and occupational therapy;
• Adult day services;
• Medically necessary supplies and equipment;
• In-home assistance;
• Medically necessary transportation;
• Nutritional counseling;
• Caregiver education and support; and
• Full medical and prescription drug coverage.

The model has met with a good deal of success in Central Mass., as evidenced by the steady base of expansion, said Bostek, adding that, by the start of this decade, the company was actively pursuing opportunities to bring the concept to other parts of the state.

“Based on experiences in Central Mass., we felt there was a huge opportunity to take this model into this part of the state,” she said of the Greater Springfield area. “So we embarked upon a plan to expand in Western Mass.”

The 14,500-square-foot Springfield facility is licensed to serve residents of Hampden County and a few communities in Hampshire County, said Woodis, adding that, while many of the current participants are from Springfield, several other communities are represented. To be eligible for the program, individuals must by 55 or older and meet clinical criteria that Bostek summed up with the phrase “nursing-home-eligible.”

Mary Woodis

Mary Woodis says people come to the program for their medical care, but also for the social aspects.

The current mix of participants includes individuals across a broad age spectrum, said Woodis, adding that many are in their 60s, while a few are in their 90s, and there’s one centenarian. Some have cognitive issues, such as dementia or Alzheimer’s, while others do not, and there is a growing number of what would be considered younger seniors with neuromuscular disorders such as MS and ALS.

“A PACE participant, in general, is a frail, older adult,” said Dr. Alison Grover, the on-site gerontologist at the facility. “They probably average in their low 80s with multiple medical problems and usually some difficulty with mobility and self-care.

“It’s not at all unusual to have some level of memory impairment as well,” she went on, “and it’s our mission to keep such individuals in their home as opposed to in a nursing home.”

Summit Eldercare makes this possible by providing that one-stop shopping Pam White described.

Care Package

Elaborating on this concept, those we spoke with all used the phrase ‘integrated model of care’ to describe what’s offered, meaning both medical care and the many social aspects of the PACE program available at the Wason Avenue facility.

“People come here for their medical care,” said Bostek, referring to everything from visits with Grover to occupational and physical therapy. “But they’re also here for the social aspects of this program, doing things with other participants.”

It is this “complete package,” as Grover called it, that separates Summit ElderCare from a typical senior center and adult day care facilities, and also enables older adults to stay out of nursing homes.

Woodis said activities run the gamut from arts and crafts to computer classes; from reading in the facility’s small library to healthy-cooking classes. On the day BusinessWest toured the facility, a Mother’s Day tea was in progress. Participants helped create tissue-paper flowers and also baked pies for the attendees.

The key to effectively providing this integrated model of care is teamwork, said Grover, and there are many members on the team, including nurses, physical and occupational therapists, a nutritionist, social workers, a transportation coordinator — who oversee work to get participants to and from appointments — and others.

Each day starts with a team meeting, she went on, one that essentially assesses the immediate needs of the participant population and creates an action plan.

“We talk about our participants — we talk about who may be having problems, who may be in or out of the hospital, who has a caregiver that’s been in the hospital for the past month,” she explained. “We talk about what we can do to help support the family and what the patient needs to be safe at home. We talk about whether we need to go out and see the patient at home that day. And then we go out and do our various jobs.”

This is an effective model, but one that many in this region don’t know about, said Bostek, adding that, to meet established goals for growth, the company must build awareness about the PACE concept. Meanwhile, it must also be diligent and imaginative when it comes to outreach and building relationships with individuals and agencies that might refer potential participants.

Those constituencies include senior centers and ASAPs (aging service access points), agencies that serve the elderly, as well as hospitals, primary-care physicians and specialists, elder-law attorneys, senior housing complexes, food pantries, and others.

“We really work hard to be very visible in locations where there would be a large older adult population, as well as a low-income older adult population,” said Bostek. “We do some marketing, but it’s really a grassroots approach that we take.

“You sit across the kitchen table from a caregiver and/or an older adult to talk about the program,” she went on. “We have that personalized touch, but we need to make sure that we’re out in the community and that we’re building relationships with community partners and resources, because we want to them to readily identify that this program may be a viable option for someone and refer them to us.”

Caregivers are a very important piece of this outreach process, Bostek continued, citing statistics showing that one in three Americans serve as caregiver to a spouse, older relative, or friend, and many, like White, face considerable challenges as they take on that assignment.

Grover agreed, and cited the caregiver of that aforementioned centenarian as a good example.

“That patient has medical problems and mild dementia, and is cared for by her son at home,” she explained. “In order to keep her there, he needs oversight on medical management, assistance in the home with personal care, and help to simply balance his caregiver role with other roles in his life. She needs help with personal care and mobility, and for someone like that, there aren’t many other alternatives.”

Coming of Age

There were not many alternatives for Pam White as she searched for a program that would allow her to keep working and also enable her mother to remain in her home and out of a skilled-nursing facility.

The program offered by Summit ElderCare has proven to be the solution sought by both mother and daughter, and this story is now being repeated on a regular basis at the Wason Avenue site.

These developments clearly show that the company has become a PACE setter, both literally and figuratively.

George O’Brien can be reached at [email protected]

Business of Aging Sections
Marketing to Baby Boomers Poses Challenges, Opportunities

Janet Casey, with Marketing Doctor Agency Director Bill Lucardi

Janet Casey, with Marketing Doctor Agency Director Bill Lucardi, says older Americans comprise a lucrative — and growing — market.

Christopher Rawson has seen a sort of “reset” in the connection between how old Baby Boomers are and how old they feel.

“We do marketing for a number of retirement communities, and they’ve sort of noticed a gap in age. People used to move in at 65; now they’re moving in at 75 or 80,” said Rawson, creative director at Andrew Associates, an advertising and marketing firm in Enfield, Conn.

Compared to what would be considered the older generation decades ago, he noted, “they’re healthier individuals, with better medical care, and people are staying active longer.” They’re also purchasing more, and that’s posed a challenge for companies who want to access Boomers’ deep pockets.

How deep? According to a 2012 study by Nielsen and BoomAgers, nearly 70% of all the disposable income in the U.S. will be in the hands of this group within five years. Nearly 8,000 Boomers turn 65 every day, and with Americans living longer, the ranks of the over-65 crowd will continue to swell for the next 15 years.

“Marketing to seniors effectively, and being adept at the nuances and cultural values necessary for marketing to seniors, can make or break your campaign efforts,” writes Bill Murtha, president and CEO of Roberts Communications, who blogs about societal trends at behaviorchange.net. “Why? As the famed bank robber Willie Sutton allegedly said when asked why he robs banks, ‘because that’s where the money is.’”

Importantly, Rawson said, most Boomers see plenty of life in front of them. “They don’t like someone talking to them like they’re old. The whole mantra that ‘70 is the new 60’ or ‘60 is the new 50,’ that’s really true. Older people are much more active. Some are working just because they want to do something. They’re much more involved with technology than ever before, more informed. It seems like, the last few years, everywhere you turn, you see older people on smartphones and iPads.”

Janet Casey, president of Marketing Doctor, a marketing agency in West Springfield, agrees that older Americans bring rich opportunities for travel, recreation, healthcare, and a host of other industries.

“The way I look at it, people who are 50 and older have the highest disposable income of any market there is,” she told BusinessWest. “An 18-year-old might think he wants a new car or a vacation, but if he can’t write the check, it doesn’t matter, does it?

“This is what I see in the travel industry,” she continued. “They offer so many guided trips for seniors, domestic and international — because seniors can afford it.”

But with an eye on the long term, Rawson and Casey said, they’re not throwing their money around carelessly. Knowing how to reach them — with the right messages on the right media platforms — is the key to tapping into that promising 70%.

Logged On

Take social media, for example. The sole domain of Millennials and Gen-Xers five years ago, Facebook has undergone a remarkable demographic shift. Its ease of use attracted countless parents and grandparents who enjoy keeping up with family and old friends and sharing pictures; as younger users have abandoned Facebook in search of newer and ‘cooler’ platforms, the older crowd — less transient in its social-media tastes — has stayed put.

“Seniors are the fastest-growing group on Facebook,” Casey said, adding, however, that those habits don’t cross over into Twitter, Instagram, or other popular sites. “We place a lot of ads for area hospitals — say, for an arthritis clinic or joint replacement. We know that seniors spend a lot of time on Facebook, because they have more hours on their hands than other people do. But we don’t find them on social media outside of Facebook.”

Rawson said social-media use has picked up in general among Boomers, but agreed that Facebook is ground zero.

Chris Rawson

Chris Rawson says Boomers with disposable income aren’t indiscriminate with their money, but they will respond to ads, including online pitches, for products and services that appeal to them.

“In terms of the Boomers, the 65-plus crowd, they want to see what their grandkids are doing, and Facebook has definitely shifted to an older crowd now,” he noted. “The typical user on Facebook is a 42- to 45-year-old woman with kids. The second-most-popular user is that person’s mother.”

Twitter and Google Plus are also attracting more seniors, writes Tracy Sestili at socialmediatoday.com. But these are different than the family-photo-sharing crowd on Facebook; there are more executives and small-business owners who use social media for marketing purposes.

But older Americans are definitely online. According to Pew Research, 59% of people 65 and over use the Internet, and 77% have a cell phone. Furthermore, according to a study by eMarketers, 49% of Boomer tablet users and 40% of smartphone users made at least one purchase within the past year after gathering information on their mobile device.

Still, Rawson said, “they’re very cautious. They do investigate a lot of stuff on the Internet, whether it’s advertising going on Facebook or other social media. They’re responsive to ads. They won’t click on everything, but if it’s something they like, they’ll click on it.”

And, again, Casey stressed that no social-media site approaches Facebook when it comes to attracting older users. “Many younger people have left Facebook because their parents are on there, but there’s really no other place seniors are — not Instagram, not Twitter.”

Screen Time

What hasn’t changed much is the TV-viewing habits of seniors, who watch, on average, 4.2 hours of TV per day.

“They consume more TV than the other groups,” Casey said, particularly in the daytime hours, when soaps, game shows, and talk shows dominate. Fortunately, she added, advertising during these non-prime-time hours is relatively inexpensive. “It’s a very efficient way of reaching seniors. For literally $30, you can have an ad on a broadcast station, and you can reach them.”

Multiple studies also suggest that direct mail is more effective on Boomers than on younger generations, and while newspaper readership is declining among all demographics, 65% of readers are seniors.

“Most older people are reading a daily newspaper; it’s part of their culture,” Casey said. “If you think about it, our parents wouldn’t start their day without reading the paper. With our generation and our kids, it’s not the same.”

So when targeting the senior crowd, she added, “we have great success through print, through daily and specialized publications. But there’s a huge dropoff under age 50.”

Regardless of the medium, Murtha writes, the message is everything. “As senior lifestyles change, so do their interests. Yes, they are adopting and using social media and the Internet. But they’re using it to share photos and memories with friends and family. They’re spreading and taking in news about their local community online. They’re exploring or expanding their interests and hobbies in a more intent way now that they have the time and the money to do so.

“Want to connect and reach mature markets effectively?” he adds. “It’s not all digital and online, and it’s not all print and traditional.”

And caution still reins among much of this demographic, Rawson stressed. “It’s interesting how they perceive the future; they understand they’re living longer, and they want to make sure their retirement plans last them, so they don’t outlive their money. They are very conservative spenders, but they will spend if it’s the right thing and they have the income to spend on it.”

Joseph Bednar can be reached at [email protected]