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How Can I Prevent a Fall?

Less than 60% have considered the home modifications necessary to age in place safely, says Yahoo Finance’s recent article entitled, “Prevent 300,000 Fall-Related Hospitalizations with Simple Aging in Place Home Modifications According to Lisa M. Cini.”

America’s leading aging expert compiled a list of simple home modifications to prevent falling and maintain balance while they stay home. Consider these simple home modifications to prevent falls:

  • Keep Item Within Reach. This includes your telephone and anything on a high shelf, or on another floor you may need. That way, you won’t have to stretch or balance on step ladders to reach things you need daily, since it can lead to falls.
  • Use Smart Flooring to prevent falls. For example, invest in anti-slip tiles for bathrooms and kitchens to avoid sliding on water or polished surfaces, and ensure that all rugs have anti-slip mats underneath to prevent slipping across the floor.
  • Consider Motion Activated Lighting. Install lighting with sensors to turn on when movement is detected, especially on stairs and in bathrooms.
  • Make the Garden Safe. Clear moss and old leaves from the paths to minimize the risk of slippery spaces. Avoid too many pots and ornaments as they are easy to trip over. Install lighting, so you can see your way along paths in the dark.
  • Get Rid of Clutter. Clearing clutter from steps and floors helps you to avoid slips and trips. Don’t leave things on the floor where they can cause a hazard.
  • Try Posture Exercises. Pilates and yoga will help you avoid falling by maintaining good balance, core strength and posture techniques. Some exercises are chair-based. However, most are gentle and set at a pace that the group can follow.
  • Install Handrails to Keep You Steady. Get handrails in all high-risk places, such as the shower or stairs, to prevent falls.
  • Make Your Bathroom Safe and Functional: Falls often occur in the bathroom. Today’s bathroom can include the Assisto bathtub, which features an easily accessible and ergonomic design that reduces the risk of injury and falls.
  • Voice-Controlled Assistance Devices: Play music, make calls, set music alarms and timers, ask questions and control smart home devices.

Reference: Yahoo Finance (May 8, 2023) “Prevent 300,000 Fall-Related Hospitalizations with Simple Aging in Place Home Modifications According to Lisa M. Cini”

Why Would I Put My Home in a Trust?

Putting property in a trust can make managing and distributing your assets — including your home — easier after your death. It can also have legal and tax benefits.

Bankrate’s recent article entitled, “How, and why, to put your home in a trust,” says that a real estate trust is a legal arrangement in which the owner of a home, known as the “grantor” or “settlor,” transfers ownership of the property to another entity or individual, known as the “trustee.” The trustee manages the property for the benefit of the grantor and any named beneficiaries of the grantor’s estate.

You can place your home into a trust by signing a deed that names the trustee as the property’s new owner. The deed must be recorded with the local county recording office, and then the trust is the legal owner of the property.

The home’s original owner will usually name him- or herself as the trustee, so they can maintain control of the property. However, the original owner can name someone else as the trustee. This can be helpful in case the original owner passes away. Trustees are frequently adult children of the homeowner, who will inherit the property upon the homeowner’s death.

Trusts are often used for tax, estate planning, or asset protection purposes, as — depending on the type of trust — the property can be protected from creditors and transferred directly to the beneficiaries without going through probate. Two primary types of trusts pertain to real estate: revocable and irrevocable.

Also called a living trust, a revocable trust can be changed or dissolved at any time by the grantor (creator) of the trust. A revocable trust lets a grantor control the property and make changes to the trust during their lifetime. The grantor retains the right to modify or dissolve the trust. The grantor can act as a trustee, manage the property, or appoint someone else.

A revocable/living trust states the original homeowner’s wishes upon death. When the grantor passes away, the property in the revocable trust is distributed to the grantor’s beneficiaries according to the terms of the trust agreement.

An irrevocable trust, as the name implies, is more permanent and can’t be terminated or modified by the grantor after it’s been created, unless the beneficiaries agree to the change.

Reference: Bankrate (February 21, 2023) “How, and why, to put your home in a trust”

More CPAP Benefits for Early Birds?

A study recently showed that patients with the morning chronotype used their CPAP machines for 32 more minutes per night compared with their intermediate chronotype counterparts over six months of use, according to Melissa Knauert, MD, PhD, of Yale University School of Medicine in New Haven, CT, and colleagues. Their research has been published in Annals of the American Thoracic Society.

“Understanding that chronotype can influence adherence to CPAP is another tool in the kit for sleep doctors to predict who might have trouble using CPAP and focus on patients at higher risk of not using their CPAP,” she told MedPage Today. “Ultimately, as we study and improve our understanding of the relationship between chronotype and CPAP use, we can develop specific therapies targeted at patients with non-morning chronotypes.”

MedPage Today’s recent article, “’Early Birds’ With Sleep Apnea May Get More CPAP Benefits,” explains that chronotype was defined by the Morningness-Eveningness Questionnaire (ME, which measures when a person’s circadian rhythm produces peak alertness. The researchers found that patients in the morning group were less likely to report feeling unrested during the day compared with the intermediate and evening groups. Here’s the breakdown:

  • Morning (MEQ 59 or above): 17.4%
  • Intermediate (MEQ 42-58): 28.3%
  • Evening (MEQ 41 or lower): 41.0%

The primary analysis of APPLES (Apnea Positive Pressure Long-term Efficacy Study), first reported in 2012, showed that treating sleep apnea with CPAP devices improved subjective and objective measures of sleepiness, especially among patients with severe OSA, versus a sham device. In addition, Sleepiness and functional status improve with each hour of CPAP use. Nevertheless, Dr. Knauert explained that sleep apnea is often hard to treat because many patients cannot use CPAP effectively.

Even within clinical trials, only 39-42% of patients use the device for more than four hours a night, and many patients stop CPAP use altogether. In the U.S., only 40-60% of the estimated 30 million patients with OSA remain adherent long-term.

“Anything and everything that we do to understand and improve CPAP use will have tremendous health benefits,” she said. “Understanding the mechanisms by which circadian biology impacts health is a large, untapped area for future research.”

Overall, 65% were men, and most had severe OSA and obesity, with an average body mass index (BMI) of 32, researchers said. Patients in the evening group were younger and less likely to be married. However, no significant differences in sleep apnea characteristics were noted between groups.  There were also no differences in insomnia or sleepiness. Anxiety was highest among participants with an intermediate chronotype.

On average, patients slept about seven hours per night. However, on the weekends, morning chronotype patients reported slightly shorter sleep duration than the intermediate and evening groups (7.3 vs. 7.6 and 7.9 hours per night).

Reference: MedPage Today (April 1, 2023) “’Early Birds’ With Sleep Apnea May Get More CPAP Benefits”

What’s the Latest on Benefits for Families of Service Members?

Dependent care flexible spending accounts are one of six measures announced recently by defense officials to address some needs in parental leave, childcare, education and career advancement for military spouses.

Military Times’ recent article entitled, “DoD to offer tax-saving child care accounts, other benefits for troops,” reports that the memorandum, signed by Secretary of Defense Lloyd Austin, also expands eligibility for the popular My Career Advancement Account (MyCAA) financial assistance program, to include spouses of service members in paygrades E-6 and O-3. The program, which provides up to $4,000 for obtaining a professional license, certificate, or associate degree, was available to spouses of troops in pay grades E-1 to E-5, W-1 and W-2, and O-1 and O-2 only. In addition, Secretary Austin also requires improvements to the Exceptional Family Member Program within 90 days.

The dependent care flexible spending accounts will let service members earmark up to $5,000 in pretax income, through payroll deductions, for eligible dependent care expenses. Officials hope to implement these accounts for service members by this year’s open season, which begins in mid-November.

A recent DoD survey of active-duty spouses found that 38% of those with children at home routinely use childcare.

According to Internal Revenue Service regulations, a dependent care flexible spending account can be used to pay for home and child center care, preschool, summer day camp, before and after school programs for children up to age 13 and adult day care. The money is deducted from the service member’s gross pay and deposited into the account before taxes are calculated. Childcare bills are then paid with those funds. The end result is a lower tax bill.

In addition, married service members with one child with eligible childcare expenses could get a tax benefit by contributing $5,000 to a dependent care flexible spending account. For them, the tax decrease ranges from $382.50 to $1,382.50, depending on their overall income. A 2021 DoD demographics report shows that 35% of active-duty members have children. Of those, nearly 42% have at least one child, five or younger. Another 33% have at least one child in the six to 11 age group.

In addition to these new accounts and expanded eligibility for MyCAA, Austin’s memo announced improvements to the Exceptional Family Member Program, universal prekindergarten at Department of Defense Education Activity schools and professional license portability.

Reference: Military Times (March 22, 2023) “DoD to offer tax-saving child care accounts, other benefits for troops”

How are Strokes Diagnosed?

The CDC says that a stroke happens when something blocks the blood supply to part of the brain or when a blood vessel in the brain bursts. In either case, parts of the brain become damaged or die. A stroke can cause lasting brain damage, long-term disability, or even death.

Verywell Health’s recent article entitled “Everything You Should Know About Stroke” explains that diagnostic tests for stroke include the following:

  • Brain imaging: A brain computed tomography (CT) scan frequently will spot the blood of a hemorrhagic stroke within the first hours of bleeding. Brain magnetic resonance imaging (MRI) can identify an ischemic stroke’s early, subtle changes.
  • Angiogram: This angiogram test looks at the blood vessels. Angiograms of the cerebral vessels can include computed tomography angiogram (CTA) or magnetic resonance angiogram (MRA). These tests can pinpoint structural irregularities or blood clots in the brain’s blood vessels.
  • Blood tests: while a stroke isn’t diagnosed with a blood test, it can identify stroke risk factors, like high cholesterol or diabetes.
  • Electrocardiogram (EKG/ECG): This is a fast, noninvasive test that examines heart rhythm. It can identify abnormalities associated with an irregular heart rhythm, heart attack, or heart failure.
  • Echocardiogram: This test is noninvasive and looks at the structure and movement of the heart. It can detect heart problems that increase the risk of stroke.
  • Carotid ultrasound: This noninvasive test examines the neck arteries leading to the brain. Narrowing or disease of these arteries can cause a stroke.

Sometimes brain imaging tests also detect previous asymptomatic (without symptoms) strokes.

Effective stroke care begins with a prompt assessment to determine the type of stroke, followed by rapid treatment.

Medical stabilization is needed for all types of strokes and includes maintaining optimal blood pressure, blood sugar and fluids.

Verywell Health (Feb. 27, 2023) “Everything You Should Know About Stroke”

Tax Scams Involving Charitable Remainder Annuity Trusts

The IRS has issued a warning about promoters aiming specifically at wealthy taxpayers, advises a recent article, “IRS Warns Of Tax Scams That Target Wealthy,” from Financial Advisor. Charitable Remainder Annuity Trusts (CRATs) are irrevocable trusts that allow individuals to donate assets to charity and draw annual income for life or for a fixed period. A CRAT pays a dollar amount each year, and the IRS examines these trusts to ensure they correctly report trust income and distributions to beneficiaries. Of course, tax documents must also be filed properly.

Some sophisticated scammers boast of the benefits of using CRATs to eliminate ordinary income or capital gain on the sale of the property. However, property with a fair market value over its basis is transferred to the CRAT, the IRS explains, and taxpayers may wrongly claim the transfer of the property to the CRAT, resulting in an increase in basis to fair market value, as if the property had been sold to the trust.

The CRAT then sells the property but needs to recognize the gain due to the claimed step-up in basis.  The CRAT then purchases a single premium immediate annuity with the proceeds from the property sale. This is a misapplication of tax rules. The taxpayer or beneficiary may not treat the remaining portion as an excluding portion representing a return of investment for which no tax is due.

In another scam, abusive monetized installment sales, thieves find taxpayers seeking to defer the recognition of gain at the sale of appreciated property. They facilitate a purported monetized installment sale for the taxpayer for a fee. These sales occur when an intermediary purchase appreciated property from a seller in exchange for an installment note, which typically provides interest payments only, with the principal paid at the end of the term.

The seller gets the larger share of the proceeds but improperly delays recognition of gain on the appreciated property until the final payment on the installment note, often years later.

Anyone who pressures an investor to invest quickly, guarantees high returns or tax-free income, or says they can eliminate taxes using installment sales, trusts, or other means, should be dismissed immediately. Your estate planning attorney is well-versed in how CRATs, LLCs, S Corps, trusts, or charitable donations are used and will steer you and your assets into legal, proper investment strategies.

Reference: Financial Advisor (April 24, 203) “IRS Warns Of Tax Scams That Target Wealthy”

What’s the Latest on VA’s Coverage of New Alzheimer’s Drug?

The VA has announced that it will cover Leqembi, a monoclonal antibody therapy made by pharmaceutical companies Eisai and Biogen, for veterans in the disease’s early stages. This makes the VA the first and largest health program in the country to endorse the treatment, reports’ military.com in its recent article entitled, “VA to Cover New Drug for Early Stage Alzheimer’s Disease.”

In January, the FDA granted accelerated approval for Leqembi, also known as lecanemab, when research showed that the medication slowed the physical and mental decline in some patients with early Alzheimer’s by as much as 27%. Although research is ongoing on the treatment’s effectiveness, the drug is among the first to show that it reduces beta amyloid — the toxic protein that contributes to the development of Alzheimer’s — in the brain.

“This treatment option is the latest therapy to target and affect the underlying disease process of Alzheimer’s instead of only treating the symptoms of the disease,” said Dr. Billy Dunn, director of the Office of Neuroscience in the FDA’s Center for Drug Evaluation and Research, during the accelerated approval announcement.

The VA treats about 168,000 veterans with Alzheimer’s, some of whom are in the early stages. Leqembi has an estimated cost of $26,500 a year, and a two-milliliter dose at the VA will cost the department $194.63. A five-milliliter dose will cost $486.57, according to the department’s National Acquisition Center Contract Catalog.

According to VA Press Secretary Terrence Hayes, the drug will be available only at the request of a provider to vets who “most closely align with” patients who meet the selection criteria for clinical trials. This means that the VA patients must meet the same demographic and health history standards as those studied by the manufacturers.

“Each dose of the medication administered for each patient will be tracked and monitored for safety and appropriateness of use, in real-time, by VA’s Center for Medication Safety,” Hayes said in an email to Military.com. “VA will continue to monitor the clinical evidence and safety data for this agent and adjust the criteria for use as appropriate. VA also has capabilities and safeguards in place that are very different from the private sector, such as the ability to conduct real-time medication-use evaluations that will allow for continued safe use of the medication.”

Leqembi is approved for use only in patients with early Alzheimer’s with a “confirmed presence,” via a brain scan, of beta amyloid.

Reference: military.com (March 14, 2023) “VA to Cover New Drug for Early Stage Alzheimer’s Disease”

Use Estate Planning to Prepare for Cognitive Decline

Since 2000, the national median age in the U.S. has increased by 3.4 years, with the largest single year gain of 0.3 years in 2021, when the median age reached 38.8 years. This may seem young compared to the life expectancies of older Americans. However, the median age in 1960 was significantly lower, at 29.5 years, according to the article “Don’t Let Cognitive Decline Derail Well-Laid Financial Plans” from Think Advisor.

An aging population brings many challenges to estate planning attorneys, who are mindful of the challenges of aging, both mental, physical and financial. Experienced estate planning attorneys are in the best position to help clients prepare for these challenges by taking concrete steps to protect themselves.

Individuals with cognitive decline become more vulnerable to potentially negative influences at the same time their network of trusted friends and family members begins to shrink. As people become older, they are often more isolated, making them increasingly susceptible to scams. The current scam-rich environment is yet another reason to use estate planning.

When a person is diagnosed with Alzheimer’s or any other form of dementia, an estate plan must be put into place as soon as possible, as long as the person is still able express their wishes. A diagnosis can lead to profound distress. However, there is no time to delay.

While typically, the person may state they wish their spouse to be entrusted with everything, this has to be properly documented and is only part of the solution. This is especially the case if the couple is close in age. A secondary and even tertiary agent needs to be made part of the plan for incapacity.

The documents needed to protect the individual and the family are a will, financial power of attorney, durable power of attorney and health care documentation. In addition, for families with more sophisticated finances and legacy goals, trusts and other estate and tax planning strategies are needed.

A common challenge occurs when parents cannot entrust their children to be named as their primary or secondary agents. For example, suppose no immediate family members can be trusted to manage their affairs. In that case, it may be necessary to appoint a family friend or the child of a family friend known to be responsible and trustworthy.

The creation of power of attorney documents by an estate planning attorney is critical. This is because if no one is named, the court will need to step in and name a professional guardian. This person won’t know the person or their family dynamics and may not put their ward’s best interests first, even though they are legally bound to do so. There have been many reports of financial and emotional abuse by court-appointed guardians, so this is something to avoid if possible.

Reference: Think Advisor (April 21, 2023) “Don’t Let Cognitive Decline Derail Well-Laid Financial Plans”

Should You have a Pet Trust Created?

The infamous Leona Helmsley was the subject of as many headlines after her death as when she was alive, mainly because she left millions in trust for her dog, “Trouble.” However, you don’t have to have millions to want to protect your faithful pet’s future in the event of your passing, according to a recent article, “Pet Trusts Are Worth the ‘Trouble’” from Wealth Management.

Pets are legally considered the personal property of their owner, in the same way, one owns a house or a car. If no planning has been done, your heirs can inherit the ownership of your pet. However, they won’t be required to care for your pet. Instead, they can take the pet to a local shelter or, as often happens, abandon it. However, there are steps you can take to protect your animal companion.

Ask two friends or relatives if they would be willing to serve as emergency and/or long-term caretakers. Provide them with contact information for your veterinarian, discuss your wishes about what should happen to your pet and make sure they have each other’s contact information. Have a frank discussion of how expenses will be covered and stay in touch with them. Circumstances can change over time; if they move, have a health issue, or can’t manage the care of your pet, you’ll want to know about it.

Planning for pets has both legal and financial considerations. A pet trust may be created as part of a living trust or as a stand-alone trust. The named trustee has access to funds, and the language of the trust includes directions as to how funds should be used for your pet and how to distribute any remaining funds upon the death of your pet. Pet trusts are now valid in all states.

Note that a verbal agreement to care for your pet may not be legally enforceable. Therefore, you may prefer to use a pet trust. While you can put a provision in your will for the care of your pet, unlike a trust arrangement, there is no continuing obligation for the executor under a will to ensure the pet’s well-being once the estate administration is completed. Instead, you’ll have to count on the moral commitment of the caregiver to take care of your pet.

Planning for your protection shows why a pet trust is a good idea. For example, your Power of Attorney names an agent to act on your behalf in the event of your own physical or mental incapacity. It is possible to include specific funds in a Power of Attorney to maintain and support companion animals. However, this terminates on your death. A trust remains in effect for as long as the terms dictate, whether you are incapacitated or deceased.

Another option is to make arrangements with a humane society or animal rescue group to take possession and care of your pet. This may require making a specific donation to the group and having confidence that the organization will be operational as long as your pet lives.

Speak with your estate planning attorney about your state’s rules on pet trusts and plan for yourself and your beloved animal companion. You’ll then rest easy knowing you are both protected.

Reference: Wealth Management (April 14, 2023) “Pet Trusts Are Worth the ‘Trouble’”

Is Low Bone Mineral Density Linked to Dementia?

In a study of community-dwelling older adults, every standard deviation lower BMD at the femoral neck was linked with a 12% higher risk for developing all-cause dementia, says Mohammad Arfan Ikram, MD, PhD, of Erasmus University Medical Center in Rotterdam, The Netherlands, and colleagues.

MedPage Today’s recent article entitled, “Osteoporosis: Another Dementia Predictor?” says that each standard deviation lower for femoral neck BMD was also linked with a 14% higher risk for Alzheimer’s disease during the 11-year follow-up, the group wrote in Neurology.

When the researchers looked at only the first decade of follow-up, older adults falling into the lowest group of BMD in the femoral neck had a twofold higher risk for dementia than those in the highest tertile. In the first 10 years, those in the lowest tertile for trabecular bone score and total body BMD also saw a significantly higher risk for developing all-cause dementia. However, when expanding to the entire follow-up period, only low femoral neck BMD was still significantly connected with dementia onset.

“Low bone density and dementia are two conditions that commonly affect older people simultaneously, especially as bone loss often increases due to physical inactivity and poor nutrition during dementia,” noted Ikram. “However, little is known about bone loss that occurs in the period leading up to dementia. Our study found that bone loss indeed already occurs before dementia and thus is linked to a higher risk of dementia.”

“Previous research has found factors like diet and exercise may impact bones differently as well as the risk of dementia,” Ikram added. “Our research has found a link between bone loss and dementia, but further studies are needed to better understand this connection between bone density and memory loss.”

“It’s possible that bone loss may occur already in the earliest phases of dementia, years before any clinical symptoms manifest themselves,” he explained. “If that were the case, bone loss could be an indicator of risk for dementia and people with bone loss could be targeted for screening and improved care.”

The researchers also noted that prior data suggested a link between low femoral neck BMD with structural brain changes, which may be a major driver of elevated dementia risk. These changes include declined white matter volume, increased white matter hyperintensity volume, the occurrence of silent brain infarction and progression of parenchymal atrophy.

In addition, it’s possible that these individuals experienced some loss of cognition that subsequently lead to poorer dietary nutrition and lifestyle habits.

Reference: MedPage Today (March 22, 2023) “Osteoporosis: Another Dementia Predictor?”

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