As people age, they often seem to be taking more and more pills each week or each day. Some don’t take any at all, but other people seem take 10 to 15 different pills each day, and some pills are taken a few times each day.

Is all the necessary? Are some meds overlapping with others? Is there a single doctor who has looked at all the meds to determine if they’re all needed?

My first exposure to this was when my father was ill and on several different medications and he just didn’t seem like his normal self. When he complained to the doctor and the doctor took a look at all the medications, he realized that different doctors had prescribed overlapping drugs for the same condition and hadn’t told him to stop taking the old ones when they added a new one. Once half of the medications were removed, and the dosage of the others reduced, he felt much better and was back to his old self.

I’m not a doctor, and I’m not giving you medical advice or suggesting that you stop any of your medications, but I do suggest that you periodically have a single doctor look at the array of medications you’re taking to see if some overlap for the same purpose, or if some are simply no longer necessary.

What about medicines with anticholinergic properties? These might be prescribed or available as over-the-counter medicine. Many people think any over-the-counter medicine is harmless, but that may not be the case, and many of these drugs, alone or in combination with others, can cause dementia-like symptoms, or increase a person’s level of dementia.

Most people don’t live to their 90th birthday, but I had a recent client who was 97 years old. He went to the hospital following a fall from his ladder when he was outside trying to fix a bird feeder before a big storm hit. He went from the hospital to the nursing home and was more and more alert every day after the pain medications were stopped. When he later transferred to a board and care facility, his mental ability increased rapidly. After a week or so there, he went home and was laughing, joking, playing cards, and having a great time.

When a geriatric physician reviewed his list of medications once he got home, the family realized that he was on far too many drugs, and the dosage was much higher than necessary on some of the drugs. His broken bone healed, and, perhaps more importantly, the family saw a tremendous recovery in his mental abilities as he got further and further away from so many unnecessary medications.

The wonders of pharmacology have saved and improved millions of lives, but I suggest that once in a while, people have a single doctor review all of their medications to see if some are no longer needed, or are overlapping with other drugs and the result is a higher dosage than necessary for that particular issue that the physician is trying to address with the medication.

No, don’t stop all your meds. It may be the medications that are keeping you alive. Just give it some thought and occasionally try to get one single physician to review your overall list of medications and dosages. Cleaning up your medication list may also clear up your mind a bit.

Don’t Go Home!

If you or a loved one is in the hospital, the natural thing is to want to go home. That’s clear. But what if you’re in the nursing home? Same thing. Residents want to go home, and their families want them home.

But what if there’s nobody to care for the ill person? What then? Think carefully before you take someone home. Can they be left alone? Can they take care of their activities of daily living? Will they be safe?

I had a case last year with a severely disabled man who was being discharged from the hospital. His second wife could no longer care for him, so she wanted him placed in a nursing home. The man’s daughter from his first marriage, along with one of his sisters, decided to take matters into their own hands and kidnap the disabled man from the hospital. After two nights at the daughter’s house, they realized that they could not care for the man, so they took him back to the hospital emergency and just dropped him off and left him there. Yes, absolutely CRAZY, but it happened.

The hospital finally discharged the gentleman to a nursing home, and now Medi-Cal is paying for his care and he has 24-hour nursing care available to him. Everything finally worked out well once the family stopped fighting and finally followed my instructions — but it took a court case and the judge’s order for the daughter and sister to back off. Unnecessary expense and stress for the family.

A couple of weeks ago I had a similar situation where the disabled man had been living with his caregiver for several years, but then fell and banged his head and had to go to the hospital emergency. The doctor said he could no longer go home, but the discharge nurse at the hospital was demanding that the man go back to live with his caregiver, despite the doctor’s statement that he should not go back there. The disabled man had been fighting with his caregiver for years, but the main reason he could go back there was because the caregiver was his 94-year-old father! Yes, it was clear that the 94-year-old father could no longer care for his severely disabled son, and that for the health of both of them, the son had to be placed in a skilled nursing facility.

Another family came to me for help with their mother. She needs the care of the nursing home, but the social services person at the nursing home is telling her husband that he should take her home and she’ll be much better off at home on hospice. Really? The husband is 91 years old and already has significant dementia. The adult children know that he’s unable to care for their mother, but the nursing home staff is trying to convince him to just take her home. Why would they do such a thing? Because the nursing home can make more money by getting her out and using her bed for someone who comes directly from the hospital on Medicare (not Medi-Cal) and the nursing home has a much higher profit on the Medicare patients. It’s not about the care — it’s about the nursing home profitability. And unless you know the ins and outs of the billing and the system, you’ll be at a disadvantage when working with hospital and nursing home staff who are trying to bamboozle you for their own benefit.

Know your rights. Be informed. Work with an experienced elder law professional to guide you.

A recent article in the New York Times stated, “We have a big problem paying for long-term care in this country, although most people don’t wake up to the challenge until it affects their family directly.”

Many families overpay simply because they don’t know the rules and aren’t aware of their rights. Don’t let that happen in your family. Make sure that you learn the basics before you need to get care for someone, and make sure that your legal documents will allow the individuals you trust to make the right decisions for you.

There’s a lot of confusion on when Medicare will pay for a skilled nursing facility. A Federal court case in early 2013 clarified that the nationwide standard applying Medicare benefits for long-term care in skilled nursing facilities was incorrect. The old rule-of-thumb standard was the “Improvement Standard” that resulted in many seniors being inappropriately denied Medicare coverage for something that should have been covered by Medicare. Now, more than five years after that court decision, many nursing homes are still misapplying the standard and denying Medicare benefits to residents.

Despite the court decisions, we still regularly see nursing homes acting in violation of the law with overbilling and improper evictions. Why? The nursing homes can increase their profits by violating the law, and most families never know that they’ve been scammed into making unnecessary payments. The insurance companies go along with this too because it saves them billions of dollars annually when they don’t have to pay the residents’ portion of the nursing home bill that Medicare doesn’t cover.

Most nursing homes follow the law, or can be nudged to follow the law, but some nursing homes act aggressively with false billing and improper evictions.

I was recently preparing to sign documents at a nursing home in the late afternoon, and then the family called to advise me that my client had died that morning. When the family came to see me a week later, I found out that they had been charged a little over $10,000 at the beginning of the month. I couldn’t understand why the family had been charged when the elder was still covered by Medicare. I thought it was wrong, and I advised them to go back and seek a refund.

A few weeks later the family was happy to advise me that the nursing home had immediately given them back a little over $6,000. Wow! … That’s great, but what about the remaining $4,000? Why wasn’t that returned?

I told the family to send the nursing home a signed letter and ask for a written reply from the nursing home explaining exactly why the nursing home was keeping the $4,000 amount and not returning the entire amount to the family of the deceased person.

After three letters from the family and still no response, the family phoned the nursing home and was told that they could come in and discuss the issue. The nursing home cleverly never put anything in writing. They simply explained that it was a billing error. They said that the deceased woman should have been kept on Medicare, but it was now too late.

That’s wrong in many ways. The nursing home could have returned the improperly charged amount to the family, and the nursing home could have corrected their error with Medicare. The more likely scenario, however, is that Medicare paid the nursing home and the nursing home also kept the family’s money. That’s double dipping. It’s called fraud.

Learn how things work. Don’t allow the nursing home to charge for something the elder is already entitled to under Medicare benefits.

Good News / Bad News

Covid has been bad news with illness and death for millions, the loss of loved ones and caregivers for millions, and economic turmoil for millions more.

When the pandemic first took off, the hospitals needed thousands of respirators. The good news was that the government had thousands in storage. The bad news was that the vast majority of those didn’t work. Good news and bad news.

Despite the losses from the outbreak, the good news has been the success of the vaccines we have available in the US. In other countries, the success has varied.

The good news in the Seychelles, Bahrain, Chile, and Mongolia was that they got out of the gate very fast with high vaccination rates in their populations. The bad news was that all four of those countries used Chinese vaccines which apparently weren’t very effective, and soon all four of those countries ranked in the top 10 countries of the worst outbreaks worldwide. Yes, good news and bad news.

What about your estate plan? If you have one, that’s good news. If it won’t work when you need it, that’s bad news. Will it work? People counted on those Chinese vaccines to work, but it appears that they weren’t effective.

Does your estate plan reflect your current wishes? Are the right people in charge to look after your interests? Will the results be good news or bad news?

We often see trusts that don’t reflect the person’s current wishes because they just haven’t gotten around to making the updates. But in some cases, the trust was wrong from the beginning. It simply wasn’t a good trust.

In a recent case with a husband and wife, the trust says that if either is incapacitated, they agree to resign from being Trustee. The next paragraph gives a committee of people who will decide whether the person is incapacitated, and if two of the three say the person is incapacitated, then the person agrees to resign. (Committee of three is pastor and two medical doctors.) The problem with the trust is that there is no third step for removal of the Trustee if he or she refuses to resign, and now the couple has waited too long and the husband’s dementia has progressed to the point where he no longer has the mental capacity to resign. I cannot allow him to sign any documents at all. He can say his name, but he doesn’t know that he’s married to his wife, and when asked for his town, city, street, or number of children, he can only repeat his name. — He can no longer sign any legal documents.

The wife has exhausted their liquid assets in paying for their stay at an assisted living facility, and now she’s facing the prospect of selling their residence and paying a huge amount of capital gains tax. Due to many different circumstances, and waiting too long to act, she’s now facing a dilemma and has a poorly written trust.

Where do you stand on this issue for yourself? Do you have a good trust? Does it reflect your current wishes of who you want in charge and how you want any remaining assets distributed after your death?

If you don’t have a trust, go see a qualified attorney who practices elder law and estate planning. If you have a trust, make sure it reflects your current wishes and will work when you need it to work.

Protect yourselves. Protect your families.

What’s hospice, and how does it work?

The formal definition of hospice, as per Medicare, is that hospice is for people who are terminally ill and not expected to live more than 6 months.

People need to understand that hospice is intended for people who are terminally ill, and the focus is on care in the form of comfort, and not on care for curing the person’s illness.  Hospice care starts when your doctor and the hospice doctor certify that you’re terminally ill, which means that you are not expected to live more than 6 months.

Medicare explains it as follows:  When you choose hospice care, you decide you no longer want care to cure your terminal illness and/or your doctor determines that efforts to cure your illness aren’t working.

There are people who actually “graduate” from hospice. It’s very rare, but some people placed on hospice later improve to the extent that they no longer need hospice care. In one case that I heard of, the woman actually went home and eventually started working again. Highly unusual, but it happens.

Hospice care is generally provided in the home, and for many people, that’s exactly what they prefer.

But have you prepared all the necessary legal documents ahead of time for any decisions that need to be made while you’re still alive, and for people to follow your wishes after your death?

All too often, I am asked to visit someone on hospice to prepare their legal documents, but sometimes the family has simply waited too long, and the person cannot make legal decisions or sign anything. This often leaves the dying person and the family in a very difficult position.

Who can make the person’s healthcare decisions? Who can pay their bills and make their financial decisions? Who will get their assets when they pass? Who’s in charge?

These are all very real questions that need to be given a lot of thought while the person is still of sound mind and can make the decisions their way without being unduly influenced by others.

I recently had a visit from siblings who accused one brother of stealing from the brother with Alzheimer’s, and of having the ill brother change his power of attorney after the ill brother was already diagnosed with Alzheimer’s.

Picking the right people to make decisions for you is critical, and having the right documents put into place while you’re still mentally competent is also critical. You want the right people making your decisions for you, and you want your assets to go where you decide you want them to go upon your death.

The last thing you need is for you to have your hard-earned money stolen from you or your beneficiaries, or to have your assets spent on a litigation battle between your heirs and other beneficiaries.

Take care of things while you can and appoint people you trust to make the right decisions for you and follow your wishes.

What is a Power of Attorney? Sometimes it’s called a Financial Power of Attorney. It’s a document that gives authority to your named Agent to act for you in various situations.  That may be paying your bills, accessing your bank accounts, closing your accounts, or even selling your residence.

Have you named a successor Agent? Maybe you named your spouse or your oldest child as your Agent, but what if that person cannot act for you. Have you named an alternate so that you have some back-up?

Is your power of attorney elder law friendly? An example of the importance of this is whether your Agent can protect your assets and get you onto government benefits such as Medi-Cal if you need assistance at home or you want Medi-Cal to pay for your nursing home costs. It’s not just a matter of the application, but also allowing transfers of assets for eligibility for those benefits, and protection against the state placing a lien on those assets for repayment to the state. These are critical issues for many elders, and the lack of a power of attorney, or having the wrong power of attorney, can prohibit your family from taking the necessary actions to protect you and your loved ones.

I have seen many individuals and families face financial hardship because a proper power of attorney was not in place. Getting a good power of attorney is not difficult. Not having the right one in place when you need it can be devastating.

Every adult should have the right kind of power of attorney in place and have the best Agent and successor Agent available to take action to help them. It’s one of the most important documents that a person can have. If you don’t have a durable power of attorney in place, get one. If you have one, make sure that it is detailed enough to allow your Agent to take the necessary actions that may be needed to protect you, to care for you, and to protect your assets for the benefit of yourself and your family.

California Welfare and Institutions Code 15610.07 WIC — Elder abuse.

(a) “Abuse of an elder or a dependent adult” means any of

the following:

(1) Physical abuse, neglect, abandonment, isolation, abduction, or

other treatment with resulting physical harm or pain or mental suffering.

(2) The deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering.

(3) Financial abuse, as defined in Section 15610.30.

I had originally planned to write something different for this article, but this morning I received a call from an attorney friend who was trying to help his aunt. The aunt is in her late 90s and has had advanced Alzheimer’s for a number of years.  The aunt has enough income to pay for her apartment rent, utilities, and food. It turns out that she had to be hospitalized because a grandson was physically beating her. The hospital reported the abuse and it became public. Several family members had been living with the aunt because she was the “golden goose” with her income, and they could live there for free and use her money to buy food. Other family members didn’t report the known abuse because they didn’t want to lose their golden goose. The physical abuse is certainly elder abuse, and the case likely involves elder financial abuse as well because the aunt’s income was being used to support several other people to her detriment.

The first step in these cases is generally to call the Adult Protective Services (APS) office in the county where the elder resides. They have the resources and trained personnel to handle these cases. If you suspect that an elder is being abused, whether it’s physical abuse or financial abuse, report it.

I had a recent case where a son moved into his father’s big house and hadn’t paid rent for two years, so the 94 year old father, who was living in a very old, one bedroom house together with his caregiver friend, was deprived of the rental income he needed to pay for food and medicine. The son was supposed to pay his father’s utilities, but the gas and electricity had been cut off once, the water department had threatened to cut off his water, and the son had refused to pay for his father’s land line telephone, so it was cut off too. The son was taking his father’s income and only giving the father $300 a month to live on, which was not even enough to provide food for the father and his caregiver.

Don’t let these things happen to someone you know. Report elder abuse if you suspect it.

Most people know that they should have some type of an estate plan in place, but they just haven’t gotten around to it yet. Or perhaps they made a plan 10 or 20 years ago, and it’s now outdated due to family changes or tax law changes. Procrastination is the enemy of good planning. Don’t let yourself wait so long that dementia, sudden illness, or death will prevent you from doing proper planning. Plan ahead.

Good estate planning encompasses how decisions will be made if a person dies or becomes incapacitated, and elder law planning takes things a step further to look at how your assets can be protected in the event that you need nursing home care. Everyone should consider both.

If you succeed in reaching the ripe old age of 65, the odds are slightly greater than 50% that you’ll spend some time in a long-term care facility, and the average length of stay in a long-term care facility is about two and a half years. That’s a huge cost. Don’t take that gamble.

A great myth about Medi-Cal is that you can’t qualify unless you have no money at all, or that the state will take everything from your family when you die. Proper planning can change all of that. Learn what can be done.

If you don’t yet have an estate plan, you should consult a knowledgeable attorney. If you have a plan, but haven’t looked at it for 5, 10, or 20 years, I suggest that you pull it out, take a good look at it, and see whether it still accurately reflects your wishes. If your plan was prepared without looking towards the potential need to have Medi-Cal pay for your long-term care, then your existing durable power of attorney may actually hamper the Medi-Cal planning efforts that someone might want to do on your behalf. Be proactive. As Gen. George S. Patton said, “Be prepared for the unknown by studying how others in the past have coped with the unforeseeable and the unpredictable.” Don’t let yourself delay to that point where the lack of a plan hurts you and your family.