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Rates of Dementia Falling in the United States
May 2, 2016 3:27 PM by Brian Garavaglia

Recent evidence suggests the rate of dementia within the United States may actually be declining, but this appears to be somewhat paradoxical. During a time in which the life expectancy in the United States has increased to approximately 78 years of age, and since dementia in its various forms is often associated with greater levels of age, the rate reduction coupled with increasing life expectancy seems contradictory. Furthermore, the trend is not just found in the United States but in other developed countries within the world.

The rate reduction in dementia was reported in the issue of the New England Journal of Medicine published Feb. 11, 2016. The research, led by Sudha Seshadri at Boston University’s School of Medicine using the Framingham Heart Study participants, found the incidence of dementia has been declining quite dramatically since the mid 1970s, with an approximate reduction of 20% in the risk of acquiring dementia. 

What has to be put in perspective is that this does not mean on an absolute level the number of new cases of dementia are declining. As the population continues to grow, and in particular as the 65-year old age group continues to grow, the number of cases of dementia will continue to increase dramatically and will place an increasing burden of caring for these individuals in the future. Furthermore, the fastest growing part of the population are those individuals who are 80 years of age and older. It is in this group the number of individuals who have dementia will continue to grow in absolute numbers. 

So then, what is declining? It is the incidence, which is the rate of new cases of dementia. This is still very good news. The rate at which individuals are being diagnosed with dementia has increased due to a number of factors: better cardiovascular health and improved lifestyle changes. Furthermore, the average age at which individuals are being diagnosed with dementia has increased by five years, from 80 to 85 years of age. This is also further good news since many individuals are living longer and adding more functional and healthy cognitive years to their lives. 

What is the reason behind the decline in rates of dementia? The authors of the study attribute improved cardiovascular healthcare leading to some of the improvements. Closer monitoring of cholesterol, improved attention to blood pressure and quicker and more prompt attention to vascular occlusions that may contribute to cognitive decline have been targeted as some of the areas of cardiovascular improvement. It is known that considerable damage, such as through unremitting cerebral vascular accidents (strokes), if not addressed promptly and effectively, could lead to significant cognitive decline. However, the researchers state that improvement in cardiovascular care is not the only thing that has been instrumental in the decline of the rate of dementia. 

The research did not answer whether other important health interventions may have contributed to this decline in the incidence of dementia. For instance, there has been a decline in smoking, and this reduction in smoking could be important in the decline through warding off potential cardiorespiratory problems that are associated with decreased circulatory performance and reduced blood oxygenation. Furthermore, a reduction in toxic substances and oxidizing factors associated with smoking may also be important factors that play a role as well. 

In addition, many older adults have become more aware of the need for regular exercise and the need for improved diets, and this could also play a role in the declining incidence of dementia.  However, here again, the study failed to look at this and more needs to be said on this topic as well.  One also has to be mindful of many of the lifestyle changes that could have been important in this decline. As the Baby Boomer generation continues to move into the older adult years, a cohort that has been better educated than previous cohorts and has been paying more attention to the importance of lifestyle as well, it will be interesting to see if the decrease in the incidence of dementia continues.  

To further advance on the issue of a better educated cohort, education and lifetime cognitive activity, although not a panacea, appears to demonstrate an important preventative impact toward reducing the probability of future dementia. In a study examining health and retirement, people born to later cohorts that had higher education had approximately a 40% reduction in the incidence of dementia. Again, whether this was due strictly to higher education or to other factors that the cohorts had encountered that may have had a preventative impact is far from definitive.

However, even if this trend is due to current lifestyle changes, especially those that impact one’s cardiovascular health that may potentially contribute to the reduction in the incidence of dementia, one may have to wonder if this trend will continue and for how long. As issues of obesity and diabetes continue to demonstrate significant increases in our society, especially among younger groups that are currently not in the 65 and older cohort yet, and as younger generations have now started to adopt a more sedentary lifestyle with computerized technology pervading society, one has to wonder if the current reversal in the rate of dementia may be short-lived. 

Although the news of the current decline in the incidence of dementia has to be met with great applause, one has to remember that the rate being measured does not reflect the growth in the total number of those that have dementia. Furthermore, as the population continues to age, those that reach older adult years, or what has often been referred to as the old-old part of the population, 85 years of age and older, will continue to encounter more dementia on an absolute level. This means that those in our society that suffer from dementia will continue to grow, and the growth will be in large numbers, concomitant with the increasing older adult population that will approximate 20% of the total population in the next 30 years. 

Therefore, although the slowing in the incidence of dementia is very laudable, our country will continue to have to meet the ever-increasing needs of more individuals that will suffer from dementia, leading to an ever-increasing strain on family members and on our already exorbitantly costly healthcare system.   

1. U.S. Dementia Rates Seem to Be Falling, Study Finds: Decades-long review revealed risk of brain disease is dropping, while age at diagnosis is going up (Feb 10, 2016). Available at:
2. Falling Dementia Rates in U.S. and Europe Sharpen Focus on Lifestyle.  Alzforum: Networking for a Cure (Feb 12, 2016). Available at:
3. Dementia Incidence Said to Drop as Public Health Improves. Alzforum: Networking for a Cure (May 17, 2013). Available at:

Exercise is Medicine
March 11, 2016 5:19 PM by Brian Garavaglia

I have addressed this issue previously, but due to its importance, it needs to be revisited in greater detail. As we age, we tend to become increasingly less active. Furthermore, many health issues that we incur are often blamed on our aging process when, in fact, they are problems of inactivity.

How often do we hear these types of statements? “My blood pressure is high, but this is to be expected at my age.” “You can tell I’m getting older since my legs get tired easily.” “Well, my doctor tells me I have a heart problem, but at my age, something has to be wrong.” Not only do we hear these comments frequently, passively resigning ourselves to not being able to change the course of health and aging,   but we will often justify our symptoms of disease as a type of “new normal” for our age. This is often manifested by comments like, “I have trouble sleeping and feel tired quite often during the day, but that is normal when you are as old as I am.” Furthermore, when we do encounter health symptoms that need to be ameliorated, what often comes to mind is, “Let me call the doctor and get a medication to get rid of the problem.”

What if you did not have to get a medication that would make you feel better? What would you say if the most important medication for preventing disease and illness and enhancing one’s functional existence and longevity is free? You may think I was peddling something, but in reality, there is a medication that is free and continues to be the most effective intervention: exercise.

I can anticipate what you are thinking. This guy is crazy. Exercise as a medicine? Where did he get such an outrageous idea? Well, I wish I could take credit for the idea, but it’s not mine at all. In fact, it is currently being promoted by the medical industry throughout the world, and the American College of Sports Medicine now has a certification is this area. More important than that is the social movement in the healthcare industry to promote exercise.

Think about this for a moment. Physical inactivity is the leading cause of death in the world today.1 Human beings, as biological organisma, evolved to be active. Yet, we have become increasingly inactive as a species. Today, approximately one-third of the world can be categorized as physically inactive. In addition, physical inactivity is one of the leading contributors toward premature mortality.1 During a period in which we have become increasingly concerned about living longer—and have heard so much about touted “anti-aging” remedies, often with little if any scientific evidence to support their stated claims—we often overlook the best and most scientifically supported type of intervention to live longer and healthier.

Why have we continued to look for longevity in a bottle or pill when exercise is readily available and free? The answer is that most people want to maintain their increasingly sedentary lifestyle, using a pill or elixir that would allow them to do so. When many individuals think of exercise, they often conjure images of gyms and boring, strenuous activities that are highly repetitive and monotonous.

This is just not true. The American College of Sports Medicine, as well as other important health professional organizations such as the American Heart Association, has promulgated some important guidelines related to increasing activity and maintaining healthier lifestyles. People of all ages, including older adults, should engage in a minimum of 150 minutes of moderate exercise each week. This roughly equates to 30 minutes of exercise five days each week.

Here is the happy news. It could be is simple is walking, but gardening, cleaning out your basement, cleaning the house or walking at the mall also count as forms of exercise that add to the minimum of 30 minutes of exercise for the day. The goal of all individuals should be to spend less time sitting and more time moving each day.

As simple as this is, it has become increasingly more difficult to carry this out in recent history. The impact of our increasing technological innovations, and their subsequent influence on our daily lives, has continued to make this a surprisingly difficult undertaking. During a period in which technology benefits many areas of our lives, it has also become an obstacle toward allowing us to remain healthier through movement and exercise.

We know what we need to do to live longer and remain healthier, and exercise is at the cornerstone of this. Exercise is not just for those who are young, however; it increases in importance as we get older. Moreover, it is a medicine—the most important medicine available for preventing, curing and rehabilitating individuals.

The “exercise as medicine” terminology is not something being used lightly. Exercise is medicinal. It is a biophysical process that induces biophysical and biochemical changes within the body. Furthermore, you do not need a physician’s prescription, an insurance card or a pharmacist’s instructions in order to promote one’s health and longevity through exercise. What is needed is a change in our mindset and culture.

There has been an advocacy within organizations embracing the “Exercise is Medicine” movement to make questions about exercise part of the vital signs process addressed during any physical examination. Just as blood pressure, pulse, respiration and temperature are often the first things taken during a doctor’s appointment, many advocates think questions about the amount of daily or weekly exercise should also be part of the visit.

Another important cultural change is to make sure that all individuals are aware of the importance of exercise and the amount that should be done. For children, the goal is 60 minutes each day. For adults, regardless of age, the target is to average 30 minutes a day, but it can also be allocated in other increments as well. Nevertheless, getting adults, especially middle-aged and older adults, to build constructive exercise habits is an important part of preventative healthcare, which ultimately can help reduce the increasing cost of healthcare and enhance functional aging and longevity.

Changing how we view exercise is very important as well, especially in dispelling myths about it having to be arduous and monotonous. Activities such as gardening, bicycling or walking along a beach are often enjoyable and are still exercise. Thinking about doing something enjoyable that also causes movement should be the goal

It was mentioned that 150 minutes each week is the minimum goal for enhancing health and well-being. It should also be mentioned that the reduction in mortality by transitioning from a sedentary lifestyle to this modest level of exercise is enormous. This leads to very significant enhancements in one’s functional capacity and longevity. Furthermore, one does not have to set aside 30 minutes each time for exercise. It could be done in smaller increments, such as 10 minutes three times a day and the same benefits are still incurred.

What is necessary is to build an exercise prescription mindset—thinking about what you can do all the time to get some form of exercise. For example, getting up from the table after eating or off the couch after sitting can be followed by 10-20 squats to enhance leg strength. While cooking , individuals can take can goods and lift them with their arms for five minutes. When shopping, they can park farther away so the walk is longer to the building—or even walk the parking lot for 5-10 minutes before going into the store. Building exercise habits throughout the day can ultimately enhance our nation’s health—in particular, the health of our older adult population.

Exercise is medicine—the most powerful medicinal force that we have available to us—and it does not need a prescription or pharmacy visit to be achieved. Yet, we often are dismissive about its power and importance. This dismissive attitude is also found within the professional community.

The power of exercise to prevent and even ameliorate conditions like heart and circulatory disease, diabetes and even certain forms of cancer has been well-established. Its ability to slow the aging process by maintaining muscle and bone strength and endurance has also been well-documented. Today, people will spend millions of dollars on pills with sensational health claims, but little, if any, scientific backing. Yet, exercise is often looked at dismissively and as activity meant only for the young.

The quicker we build a mindset that provides attention toward monitoring daily levels of exercise at all ages, the quicker we can make an impact on enhancing the health of our overall society. The potential dividends are enormous—not only for enhancing life expectancy, but for also enhancing the health and well-being of our society, reducing the cost of healthcare and improving the overall functional existence of our aging population.




American Medication Use Continues to Increase
December 11, 2015 3:08 PM by Brian Garavaglia

A recent study reported in the Journal of the American Medical Association found a sobering trend: An apparent increase in the usage of prescription medication over a decade-long period. The study was done respectively, analyzing data from the National Health and Nutrition Examination Survey database from 1999 to 2012. It contained the survey results of approximately 38,000 individuals. The study found a significant increase in the number of prescriptions medications that were used over this period of time.

During this decade-long period, a period that goes from 1999 to 2012, prescription drug use continued to increase. The percentage of the adult population reporting prescription drug use in 1999-2000 was 51%. This increased during the 2011-2012 period to 59%. However, more important than just the nominal increase in usage was the increase in the population according to age. As individuals became older, prescription drug use generally increases. However, the study found that adults are now using an increasing number of prescription drugs as compared to a decade ago. Over this period of time those aged 40 to 64 who used one or more prescription medications increased from 57% for the 1999-2000 period to 65% during the 2011-12 period. For those who were 65 years of age and older, a 6% increase was found to exist, increasing from 84% to 90%.

However, even more disconcerting was the increase in polypharmacy use. Polypharmacy use was defined as the use of five or more prescription drugs used by an individual at one time. Polypharmacy use for those 40 to 64 increased from 10 to 15%. However, for those who were over 65, polypharmacy use increased from 24 to 39% over this approximate decade under examination. This becomes a statistic that is important to take note of, especially due to the number of hospital admissions among older adults that is due to polypharmacy use. Furthermore, this is of particular concern since as one ages the potential sensitivity toward medications can also increase, leading to many forms of adverse reactions. These adverse effects are related to the pharmacokinetic changes in the body, especially changes in the ability to metabolize medications. Generally speaking, as individuals age the body’s ability to breakdown and eliminate many of these medications is reduced. Moreover, changes in the body’s composition, especially in fat and fluid composition, can dramatically alter the effects of many prescription drugs, making older adults more vulnerable to adverse drug effects, especially as polypharmaceutical use is increased.

In examining the medications that led to this increase, antihypertensives played one of the largest roles. Over the period of time that was examined by the study, antihypertensives increased from 20 to 27%. Drugs used to treat cholesterol and triglyceride levels, antihyperlipidemics, increased approximately 10%, from 6.9 to 17%. Narcotics, which are major opioid pain medications of the morphine-type classification, increased from 3.8 to 5.7%. Antidiabetic medications increased in use from 4.6 to 8.2%. In addition, antidepressant medications witnessed an increase from 6.8 to 13%. This is not all of the medications as well as their associated increases that were found by the study. However, it should nevertheless provide some understanding of the growing amount of medication usage that is found in our society in general, and among the older adult population in particular. Furthermore, with this increase in the number of medications that is being used among the older adult population, especially the level of polypharmacy usage that exists, come an increasing problem of medication management and its increasing therapeutic complexity. Moreover, one has to be increasingly mindful of the level of medication usage found among the older adult population coupled with the differential pharmacokinetics that often play a role in many older adult’s treatment regimes, which all too frequently is overlooked, leading to adverse reactions and unnecessary hospitalizations.

The study found that almost 40% of the United States population, 65 and over is currently taking five or more prescription medications. The elderly have consistently had the highest rates of prescription drug use, so this in itself is not surprising given their level of morbidity. However, apparently this part of the population is now taking a higher average amount of medications than ever before.  With each additional medication the complexity for medical management increases along with the potential adverse effects that are faced by the elderly. Furthermore, the study did not look at other factors such as over-the-counter medication use and the current increase in alternative herbal supplements that further compound the complexity of adverse drug occurrences happening.

Given the results of the study, especially the increasing polypharmacy use that was found to exist, Alex Macario MD, writes, “The important finding of polypharmacy raises other crucial questions for policymakers and health systems, such as whether a primary physician is managing the patient’s multiple medications to ensure that each is warranted and that the combination is optimal.” As the litany of medications increases, not only does the mismanagement of medication use increase among the elderly taking the medications, but also among the physician who is trying to manage the medications as well. They may often not be totally aware of the possible adverse interactive effects that could possibly exist among all the medications. In addition, since many physicians often have time limitations that exist with the elderly patients they see, this further limits their ability to often properly investigate whether any additional medication could possibly lead to an adverse drug occurrence happening if prescribed.  

In a culture that is often looking for quick fixes, medications are often thought to be our best answer. For most issues prescription medications are often prescribed judiciously. However, part of the answer to our escalating rate of drug use may also be due to the “medication quick fix culture” that has not only become inculcated into the mindset of the elderly community, but also among the professionals who serve this community. With rates of obesity increasing, a continued reliance on fast food, and a continuous amount of poor lifestyle choices that aid in advancing diseases as we age, we have come to think that there is always some pill that can be found that can reverse everything that has cumulatively led to many of our illnesses. With a culture that continues to emphasize therapeutic intervention rather than prevention, looking for a medication to reverse and correct, rather than other strategies to prevent in the first place has been the prevailing mantra. In an era when we are experiencing runaway medical costs, especially on the pharmaceutical level, individuals are inundated with drug advertisements encouraging them to run to their physician and request the advertised drug. Furthermore, in an era of patient competition, many physicians often readily capitulate to the requests of their elderly patients for the medications that they request.  

Therefore, what the study shows is more than just an increasing amount of prescription medication use. It is reflecting many of the cultural aspects regarding health, lifestyle, and intervention that we have come to casually acquiesce to. It is not just indicating a polypharmaceutical use increase; it is indicating a quick-fix cultural mindset that if not controlled will continue to led to escalating costs, heightened pharmaceutical use, and potentially increasingly life-threatening complications for our population.

1. Macario, A (2015). Are Americans Taking Too Many Medications?  Medscape,


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Exercise as Medicine for Elder Depression
October 27, 2015 8:01 AM by Brian Garavaglia
Depression in the elderly is common. Many older adults with depression often go undiagnosed or misdiagnosed. Those that are diagnosed are often placed on medication. Since many older adults are already on an average of four medications, with the potential for adverse effects increasing as more medications are added, it is welcoming news to often see modalities of treatment that do not use medications and can frequently even produce superior results to those that are treated with medication. Exercise appears to be a treatment modality that is showing great promise toward reducing depression and as such, doing so without adding to many older adult’s already cluttered plethora of prescription drug use. 
Researchers at Duke University have found that exercise could have dramatic effects on treating depression in older adults. What is even more compelling are the findings that exercise may be more effective in relieving depression than prescription medications, as well as even being more beneficial in reducing the likelihood for relapses in depression. This is very good new since abating depressive symptoms without adding additional medications provides a healthier and often safer benefit. Furthermore, not only do more medications add to the likelihood of adverse effects through problematic interactions, but adding additional medications to an already large number that many older adults take on a daily basis leads to medication management issues that often further lead to many failing to take certain medications in a timely and appropriate manner. 
The study that was undertaken at Duke University demonstrates some very compelling results of exercise being a superior modality for treating depression than traditional pharmacological intervention. The study examined 156 individuals who were 50 years of age and older with a diagnosis of major depression. They looked at three groups:  a group that engaged in exercise, a second group that only received medication and a third group that used medication and also engaged in exercise. The results were surprising. First, it was found that exercise had a superior effect in reducing depression when compared to medication. However, what was even more surprising is that one may think that if exercise was efficacious for depression, than exercise and medication combined would even be more effective. This was not so. Exercise by itself was found to be the most effective form of therapeutic modality, superior to both medication and exercise combined and medication alone. Furthermore, in a six-month follow-up examining the return of depression, those that engaged in exercise alone had the lowest rate of return at only 8%. This compared to 31% among the medication and exercise combined group and 38% found in the medication alone group. 
These are eye-opening results. First and most startling is the finding that exercise alone was superior to exercise and medication combined. However, although this is a very startling finding, it is also a very welcome one as well. Given that older adults are on large amounts of medication, finding a modality that is highly effective without adding additional pharmacological substances to the older adult’s body is a very uplifting finding. Furthermore, the rate of depression relapse being lowest among the exercise group is again a very inspiring finding by the study. 
What is also very interesting is the amount of exercise that led to these results was really quite modest. The exercise group was individuals that engaged in exercise three days each week. The exercise amounted to one-half hour of brisk walking. Here again this is a very encouraging result. Most individuals think of exercise, especially at a therapeutic level, involving high intensity, sweat, and based on arduous levels of exertion. Yet, what was therapeutic levels of exercise that significantly impacted the level of depression among those in the study was anything but high intensity and arduous. This is further good news. Most individuals frequently shy away from exercise, especially older adults, given the level of work it is thought to entail. Going to the gym, sweating, lifting weights, running until one is panting and short of breath, and feeling sore and uncomfortable afterwards is what goes through most individuals minds and most do not think that something as simple as walking can be a highly favorable and therapeutic modality of exercise. Learning that something as simple as a brisk walk that does not entail going to the gym, sweating and having sore and tight muscles afterwards is good news that may encourage many who have depressed moods to get out and start walking.  
This study is quite important on a number of levels. First, treating depression in the elderly, or for that matter any age group, without having to use medication is much more favorable than using pharmacological intervention. The potential for adverse medication effects increases with each additional medication added to a person’s total medication use. This is not to say that medication should not be used. Medication can be very important for treatment, especially in cases where the therapeutic effects of exercise on mood are refractory, where one may not be able to exercise due to physical disability or impairment, or where the melancholic features of the individual are precluding individuals from engaging in exercise. 
However additionally, and maybe even more important is that encouraging many older adults to engage in exercise may not only be instrumental in ameliorating depression or preventing depressive mood changes, but lead to pervasive health changes among older adults. The ramifications here go beyond just enhancing one’s mood. They encompass enhancing all phases of the individual’s health. It entails health care providers encouraging their clientele to become less sedentary and engage in modest levels of activity. Although most health care providers, when they make such recommendations, do so for the physical benefits that can be accrued, they must also be mindful, as this study shows, that modest levels of exercise impacts the psychological nature of the individual as well and ultimately the quality of life they live.   
The American College of Sports Medicine views “exercise as medicine.”  As this study shows, the medicinal impact of exercise on reducing or eliminating one’s depression is highly significant. Future studies need to be done to see if these impressive finding can be replicated. However, at this time, the findings from this study demonstrate how important healthy life changes can be for the quality of our life, especially for those older adults that are suffering from depression. Possibly, the most powerful therapeutic modality for addressing depression may not come from an exogenous chemical agent provided by the prescription pad, but from endogenous chemical changes created through our volitional ability to engage in exercise as an antidepressant medication. 
Study: Exercise Treats Elderly Depression ( 

Long-term Care is Just as Broken as our Acute Care Industry: Can we Learn From Japan
September 2, 2015 7:41 AM by Brian Garavaglia

In Chris Farrell’s August 21st, 2015 article, entitled, “What Japan can Teach us About Long-Term Care,” he paints picture that demonstrates our need to not only speak about the breakdown of our national healthcare indictors, our fragile national healthcare policy and the problems faced in the acute care health settings, but also the need to address the breakdown nationally of our long-term care industry healthcare industry. In reality, the long-term care (LTC) industry is mimicking many of the problems found in the larger acute care industry. Although the problems are slightly different and unique to the LTC industry itself, the LTC industry is facing many similar problems that are leading to individuals gasping for breathe as they attempt to navigate themselves through this labyrinth.

He starts the article with some sobering data. He states that the odds of those who are turning 65 and will eventually need assistance with their activities of daily living is approximately 50%. In addition he states that these individuals who utilize long-term care can expect a cost that is approximately $138,000 on average. However, and this is the distressing statistic, the median balance in individual’s saving accounts who are between 55 and 64 years of age is approximately $104,000. As one can readily see by comparing those two pieces of data, the net result of the long-term care is being placed in debt. We can see that financing of our healthcare industry is badly broken and this is also reflected in our long-term care industry.

Troubles Still Abound
Regardless of the Affordable Care Act and its provisions, we are a country, the richest on the face of the earth, which continues to struggle to subsidize healthcare, to fiscally manage it correctly and to control for proper inflationary expenditures that are astronomically driving up costs at the expense of those that need comfort and care. At a time when individuals are in need of care, when they do not need additional worries to complicate their treatment and recovery, many are entering acute care facilities, and now many LTC facilities, with the added specter of having to worry about whether they will be able to pay for their care, and if they leave the facility, will they have any personal resources left to continue to live a viable social existence.

Let me share a side story that I was shocked by since it happened to a close friend, yet stories like this are an all too frequent occurrences in our wealthy society. My friend acquired a very aggressive form of cancer. He eventually passed away within six months of the diagnosis. However, at one point during his stay within the hospital that was caring for him, a bill collector called him up from the hospital itself, asking how he was going to pay his approximately up to that point, one million dollar medical bill!  Here is a person that is dying and struggling for his life, having to receive some of the most expensive therapeutic intervention found in medicine, having to worry whether he will be allowed to get further care or be harassed by bill collectors looking to profit off his terrible and fatal diagnosis. Yet, the hospital, calling him during a period when he was still within the hospital being treated was requesting him to explain to them how he would pay his medical expenses, even though this person had a limited life expectancy with a highly aggressive form of cancer that would ultimately preclude him from ever being able to work again, or even live a viable life outside of the hospital environment for any extended period of time. An all too common occurrence, both in our acute and LTC settings:  sick people needing to worry about their treatment and getting better now being reduced to economic variables and looked at as nothing more than possible sources of revenue. Notice the antinomy that exists between the compassionate care giving organization and the reduction of the human being down to a point of a commodity for economic gain.      

Aging Population: Where is the Protection?
As the aging population in the United States continues to expand, and as healthcare problems within this population continue to expand as well, many are looking around and saying, “Who and what can I count on for healthcare protection as I get into older age.”  Medicare has been the primary insurance targeted toward the Elderly population since 1965. However, it only provides limited coverage for nursing home coverage home care, and it only covers certain individuals, the so-called “skilled population,” that has met the requisite hospital stay requirements and can enter the nursing care center with a short-term, no more than 100 day, coverage for rehabilitation.

For those that need much longer care within nursing care centers, the primary insurance has often been  Medicaid, which was never set up to be a major medical provider for long-term care, but an insurance for the indigent. Yet, it currently is the primary financial reimbursement tool used for enduring nursing home placements. Notice the term and insurance for the “indigent.”  This is often the fate of many elderly that need continued placement in nursing home settings. They often have to exhaust a considerable, if not almost complete, amount of the personal resources before Medicaid will be applicable for their coverage.

The thought of including long-term care coverage as part of most healthcare plans has never caught on in the United States and is often looked at with a level of abhorrence by healthcare insurance CEO’s since it would take away from a large amount of profit in their industry. This has often left, when it is available, separate long-term care insurance plans that are offered separately. However, as Farrell writes in his article, the long-term care insurance industry has constricted considerable, with fewer and fewer companies offering such insurance at a very high premium. Of more than 100 companies offering long-term care insurance a decade ago, the number now offering such insurance plans has been reduced to a handful. Most individuals cannot afford these plans due to their cost, which can be approximately $4,000 per year for each individual.   

As one can see, the long-term care industry is witnessing much of the same breakdown as is found in other areas of healthcare. With an older adult population of approximately 13% in the U.S. currently, a rapidly aging baby boom population, an older adult population that will reach approximately 20% over the next 50 years, a pharmaceutical industrial in which an inflationary index and level of product cost is controlled by passing the expense on to the consumer, a healthcare and long-term care industry that is seeing a sicker population that often has higher technological interventions applied to them at greater costs, and an insurance industry that still wants to make its share of a profit by passing more and more costs on to the consumer by way of coinsurances, copayments and deductibles, one can see we have a mess out there. The once thought-of security net of American healthcare and health insurance is far from providing many with any feeling of security, and it is often a net that is porous with many individuals falling through, falling down and falling out.

Japan has witnessed an incredible growth in their elderly population and currently has an elderly population that makes up approximately one-fifth of their population. The traditional cultural norm was to promote an obligation by children to care for their older parents. However, with the dramatic growth of the older adult population, many Japanese children have become quite stressed in caring for the large number of elderly within their homes. In fact, the rate of Japanese elderly abuse has increased as dramatically as their older adult population growth. In fact, a 1994 survey found that 1 in 2 family members had engaged in abusive behavior toward the elderly, and many acknowledged harboring feelings of hate toward the elderly. These are eye-opening statements that often run contrary to our conception of the Japanese population being one that is totally reverentially engaged in their behavior toward the elderly.

As more Japanese women also moved into the workforce the time they had to spend taking cover of an older adult parent or parent-in-law created monumental stressors that were formerly not seen among this young and middle age population, a stressor quite similar to what we see here in the U.S. and have given the name the “sandwich generation,” a designation often for middle-age women left to take care of elder parents and often young children still in the same household. However, in the case of the Japanese population, the sandwiching is even more prominent due to the greater number of older adults as a percentage of the total population.  

What is Japan Doing?
It must first be mentioned that the changes that the Japanese society introduced is far from being a complete panacea to the issue at hand. As the older adult population in Japan increased, the increasing number of older adults were often shunted to hospitals (often referred to as social hospitalizations), since Japan offered free hospital care for the elderly. This is similar to our society’s redirection and admission of many older adults in our past to many state hospitals, as well as unnecessary placements within nursing homes as well.

With the growing rate of elderly within the population, the increasing stressors placed on caregivers, and the public concern over these social hospitalizations, the Japanese society brought forth important reform in 2000. In 2000 the Japanese introduced a mandatory long-term insurance system. It is funded by both the general tax revenues and payroll taxes on those who are 40 years and over. Furthermore, the importance of the family has not been reduced. As is the case in our society and many others, the family remains the most fundamental source of care for the elderly. The Japanese government has also introduced important subsidies that can help support many family members in caring for their older adult family members. Some of these subsidies are also providing greater outreach to the community to assist with elderly care. Finally, the Japanese society is attempting to bring about an economic competition between the home and community-based services to help create a competitive cost-lowering economic force based on supply and demand.      

America and Its Long-Term Forecast
The Japanese, with an incredibly burgeoning population who are 65 years of age and older, which is currently slightly greater than 20% of the population, has created a structural momentum for them to address the aging population as well as many of the concomitants that have been a by-product of its growth. As was already mentioned, the changes that they have implemented are not an absolute panacea. Moreover, the changes made by the Japanese society have also come with a financial cost to its society and its members. However, given the growth of their elderly populations, with the growth of this population over the next 40 years reaching approximately 35%, the demographic momentum has forced the Japanese people to look for some way to assist with managing the needs of the ever-increasing elderly population and the needs that they specifically have that need to be addressed.  

The question for our society is how much longer can we as a society afford to wait and not make dramatic changes based on an elderly demographic that we know will only continue to grow? Currently, healthcare comprises approximately 18% of our GDP. As our population ages, this will continue to grow and further exacerbate an already existing financial healthcare crisis. However, the next question that needs to be posed is, if the older adult population will continue to increase, and if we will witness some level of increase in healthcare expenditures as part of the GDP, what can be done to 1) reduce some of the financial pressure that we face due to the ever-increasing number of chronic illnesses often presented with an increasingly elderly population and 2) what can we do to, if not stop, at least dramatically slow down healthcare expenditures in this area. In Japan, even with an older adult population of approximately 20%, their healthcare expenditures as part of their GDP is still only slightly over 10%. Therefore, Japan has already started addressing a problem, maybe slightly later than they should have based on the demographic nature of the population, but earlier on an economic level in comparison to what is found in the U.S.

The U.S. has a very explosive run-away cost in its healthcare system. Not only is this due to the increasing elderly population, but as the healthcare expenditures as part of GDP have reached 18%, far and exceeding any other nation in the world, we are spending more and getting less. The level of poor management that is found within the U.S. healthcare system leading to these run-away costs, which now comprise approximately 18% of the GDP, coupled with the fact that the elderly population is aging with the fastest growth in the elderly population being found among those who are 85 years of age and older, forebodes a continued cost-escalating crisis that will fall heavily on the elderly. Furthermore, with the oldest-old of the elderly population growing the fastest, this brings with it a much greater level of chronic illnesses and associated with this, an increasingly level of expensive care. At this point, to paraphrase an old saying, “we are getting caught waiting for the paint to dry on the fence.”  When will we stop waiting? In fact, the paint has dried, aged and is now blistering. Although our country does not have to create a facsimile of change as was found in Japan, we do have to fight the inertia of continuing to move in the same path that would ultimately only lead to increasingly grave problems for our American healthcare system in general, and more particularly, the elderly population and its healthcare needs in our country. Continuing to prolong addressing this issue in a substantive manner will only see our wounds related to health care and the elderly fester.    

1. Farrell, C. (August 15, 2015). What Japan Can Teach Us About Long-Term Care: Its program helps families shoulder the burden?
Does Race Play a Role in Alzheimer’s Disease?
July 27, 2015 10:27 AM by Brian Garavaglia

In a recent study in the journal of the American Academy of Neurology, some interesting findings as it relates to Alzheimer’s disease and race were found that may have implications for further research and treatment. There have been some assumptions that the brain changes found in Alzheimer’s disease among different racial groups are not uniform. In the recent study Lisa Barnes, PhD, of Rush University Medical Center decided to put this hypothesis to a test. She decided to examine the underlying neuropathological changes found in the brain of those that have Alzheimer’s disease based on the race of the subject.

The study examined 41 African Americans with a diagnosis of Alzheimer’s disease. They were compared with 81 individuals who were categorized as European American and also had Alzheimer’s disease. Both groups were matched on level of disease, age, sex and education. All individuals from both groups had autopsies on their brains completed at the time of their death. The researchers examined the brains of both groups for the typical brain changes often found among Alzheimer’s disease patients, such as plaques and tangles. However, in addition, they looked for vascular changes that may have occurred due to strokes, Lewy bodies, Parkinson-type brain pathologies as well as other pathological changes in the brain.                   

The results of the study showed that virtually all subjects that were autopsied had evidence of Alzheimer’s disease. However, they also demonstrated that when comparing the two groups approximately half of the 81 European-Americans had “pure Alzheimer’s disease,” which they defined as brain pathology that was exclusively dominated by Alzheimer’s disease and no other histopathology. Conversely, when the African American group was examined, they found that less than 25% of the subject’s brains showed pure Alzheimer’s pathology. The African American subjects had a greater likelihood of their dementia having a mixed pathology. Approximately 71%, as compared to approximately 50% for the European American group, demonstrated more than a single underlying pathology that contributed to their dementia. Quite frequently, the African American group’s co-morbid feature that accompanied their traditional Alzheimer’s pathology was cerebral blood vessel disease. Given that African Americans often have a greater likelihood of having blood pressure issues and diabetes, the discovery of the mixed pathology of African Americans, especially the findings of Alzheimer’s with cerebral vascular pathology, appears to make sense. 

Although these findings are quite important, it is also quite early to draw definitive conclusions about differences between different racial groups and dementia. More work has to be done to examine a larger number of individuals to determine whether the results that were found in this study continue to stand. Furthermore, it would be interesting to also broaden the examination to other groups such as those of Asian descent to see if different forms of underlying histopathology are found in their brains as well. Furthermore, do racial groups found in our society with specific underlying brain pathology continue to demonstrate the same pathology in other countries, for instance, African Americans or Asian American in the United States with those who suffer from dementia and are African and Asian and live in these parts of the world? 

Nevertheless, if the results of the study continue to be demonstrated by future studies, it has important implications for treatment of different racial groups and individuals who suffer from symptoms of Alzheimer’s disease and other forms of dementia. As the author of the study states, current treatments for Alzheimer’s disease are quite specific, with the drugs targeting anticipated underlying Alzheimer’s pathology. With the current study’s findings that many African Americans have a greater likelihood of mixed etiology for their dementia, the arsenal of Alzheimer’s specific medications currently used as treatments may be far less helpful for many African Americans that have signs and symptoms of dementia. Therefore, targeting new forms of therapeutic intervention, as well as even prevention, may be quite important for future clinical success in the treatment of dementia, especially in considering how different racial groups may have different contributing etiological factors to the makeup of their disease.   

1. Science News (July 15, 2015).  Alzheimer's may affect the brain differently in African-Americans than         European-Americans:
Garavaglia’s The One Thing
June 9, 2015 10:54 AM by Brian Garavaglia
Businesses are being bombarded with techniques to provide continuous improvement in their everyday operations.  Healthcare facilities are no different.  In fact, Total Quality Improvement, Six Sigma techniques, various forms of root cause analysis just to mention a few have become common terms and methods that are used within healthcare, and at growing rates, long-term care.  However, although we often opt for many more sophisticated forms of intervention retroactively employed, we often lose sight of the more simple proactive techniques that once habitually instilled, lead to considerable quality enhancement in our daily operations.  Furthermore, one does not have to matriculate or formally complete an MBA training program to understand a simple method for enhancing quality.  The simple method is often used when we do many things in life.  We can only address so many issues and often, just addressing one issue each day leads to great success.        

Given this, here is an idea, which I will call “Garavaglia’s The One Thing."  With such things as Parkinson’s Law and the Peter Principle, why not add another name to what I think is even a more useful principle than the previous two I have mentioned.  Yes, I am going to give it my name. However, I am providing it with my name not because it has some grandiose, arcane and previously undiscovered methodology or principle only able to be ascertained and discovered by me. I wish I could claim such brilliance. However, providing my name to it just works to create and eponymous distinction. If we institute into all the concept of "The One Thing" that we can use to improve our healthcare facilities, we can focus them toward something that needs to be achieved each day.  In fact, here is an idea for management.  Have managers keep track of The One Thing they have implemented each and every day, as well as within each department. If they are held accountable to maintaining The One Thing, you will unequivocally start to see improvements in all areas of operations. 
Stop always attempting to focus on the grand issue. Many of the most common problems are simple and right in front of you. However, they have been continuously ignored and continue to be key problems in a larger process. The One Thing could be something as simple as "today we are going to get 3 quotes on those restroom locks." It could also be something such as today, our “The One Thing” will be one person being scheduled to clean the walls in one of the restrooms. The One Thing could be today we are going to plant some flowers to enhance our outside entrance.  Or maybe, The One Thing that we are going to do today is have a fresh coat of paint applied to one of the walls in our activity room. 
When you think about it, if you commit to achieving one significant improvement each day, being mindful of "The One Thing," how many things can you find to change and continuously improve your environment — each day — for 365 days each year?  This is an important method for TQI — total quality improvement.  
Thinking about The One Thing makes you focus on change in a manageable and organized way.  It also keeps you sensitized toward looking for something each day to improve, no matter how big or small.  Eventually, all these things add up and they will also pay large dividends.    
Furthermore, if you keep this mindset — "The One Thing" — at the forefront, after a few months you are probably already looking to improve things that have already been improved. You are now building on an already improved foundation to further enhance the superstructure of the organizational environment.  How does that sound! Now you are improving on the improvements instead of having to constantly dig yourself and your business out of holes. Healthcare, as well as any other form of business, is plagued with holes, most of which are self-created. Holes are endemic to the business environment. However, often many these potential sinkholes can be prevented with the proper managerial mindset. Moreover, even though some are endemic, one can prevent them from getting larger and unmanageable. That is the essence of proper management. However, we often become complacent and ignore many of these various obvious problems, and subsequently, we are never in front of an issue, but always behind due to having to dig ourselves out of the holes that we have created. Introduce The One Thing and you now establish a culture of PROACTIVITY, not reactivity. 
It is amazing at how much money, efficiency and overall productivity is lost due to one constantly ignoring the infinitesimal issues that many think because they are small, they can wait. However, a single or a few cancerous isolates, if not addressed or eradicated in some way, can continue to grow and within a very short time one has possibly a disease that is no longer tractable. Although this is a biological scenario, it applies to organizational environments as well that often can be viewed on an organic level.  Frequently in healthcare organizations, whether they are hospital, long-term care environments, or for that matter any form of business environment, many individuals are too dismissive of the small issues that end up festering and becoming intractable and destructive over time. Again, internalize into all your workers The One Thing and this can be overcome.   
Once we have a habitually and culturally established goal that directs us toward incremental improvement, the smaller single daily improvement will lead to a magnitude of change over a few months that will often make you look back and say WOW! However, we often miss out on these WOW factors since they are too often associated with large-scale projects. However, many never are able to address large-scale problems since they become plagued in an environment of complacency, with multiple sink holes developing and that we have to constantly dig ourselves out of or fill.  An attitude of The One Thing will help to prevent such a scenario from transpiring.        

As I have already briefly mentioned, managers get sidetracked by attempting to take on monumental projects that have high levels of complexity.  At times this is quite necessary.  However, what tends to happen is that many managers get bogged down attempting to figure out how they should get started with a complex, multifaceted project. Furthermore, many managers mistakenly assume that important quality enhancements have to always be large-scale. Yet, they often overlook that often more important is the small, incremental issues that we can target each day. They often are influenced by what I refer to as the “project grandiosity delusion,” where the bigger project is viewed as the important project and they minimize the smaller steps that need to be developed before one can move to that level. It is typically these small, incremental issues, which often are not targeted, exacerbate and become large and expensive problems which, if they would have been addressed on a smaller-scale, would never had reached the magnitude that they are now at on the problem management level. Often these simple issues, following Garavaglia ‘s The One Thing rule, targeting something as straightforward as addressing a daily preventative maintenance issue, can save your healthcare facility large amounts of money. In an era in which healthcare funding and reimbursement is so crucial, attempting to save money for resident care and capital improvements is essential. As mentioned, this simple rule is important in all areas of management, not just healthcare. Managing even one’s car, and providing regular preventative intervention such as oil changes, often adds years to your car use and saves on mechanical expenses.
However, what I fear is that the admonition of following The One Thing will not be taken seriously. Why?  It is too simple.  Most individuals look at simple things and say something like, “it can’t be that simple,” leading often to sound advice being disregarded. Again, the delusion of project grandiosity is playing an important, albeit misleading role. However, often simple things, if followed, are very beneficial. It can’t be that simple that walking 30 minutes to one hour each day is healthy. Therefore people disregard it and opt for cardiovascular disease, medication and surgery. It can’t be that simple that getting regular oil changes increases the car’s life, so we opt to disregard this advice and spend money on cars before we need them. It can’t be that simple that putting a small amount of your income away each paycheck will lead to a very formidable nest egg in retirement.  So we become dependent on our hopes and aspirations for Social Security’s survival. It can’t be that simple that regularly checking the fitting around our pipes will do any good. So we end up having water leaks and large amounts of monetary resources being diverted to fixing issues related to water damage.   
Garavaglia’s The One Thing is not a panacea.  Nor will it forestall every expensive issue. There are some things, regardless of how vigilant one is, that will still break, will still need repair and will still incur large expenses. There are some healthcare issues, again, no matter how vigilant one is in their care, will still have unexpected complications and will experience negative results. However, giving heed to The One Thing will often provide a culture of continuous improvement in the quality of one’s healthcare facility and the organizational environment of the institutions.  
An Important Management Principle Can Help Prevent Unnecessary Problems
March 16, 2015 2:06 PM by Brian Garavaglia

I was watching a major professional golf tournament a few years back. Many of the golfers were having a very difficult day. In fact, many would hit their shots and get into trouble. What followed for many of them was an attempt to make too much out of an already bad situation, which in turn led to even more problems for many of these golfers. A frequent commentator for many of the major professional golf events is former golf great Johnny Miller, and he was the commentator for the tournament on that day as well. As Miller watched many of these great golfers err by attempting to make heroic shots out of almost impossible situations, what ultimately transpired to Miller's amazement was a number of great golfers with exceptional skills making very stupid mistakes and ultimately taking themselves out of contention for winning the tournament. Yet, this did not need to happen and it could have been easily prevented. It was at that time that Johnny Miller said something quite simple, yet incredibly cogent. After watching the mess that many golfers were unnecessarily making for themselves he stated, "It's like my father said, the first thing you do when you get into trouble is get out of trouble." As I listened to Miller's statement I thought what an economically well stated managerial principle, not just for golf, but for all phases of life in which we need to manage the situation.

How many times have all of us found ourselves in a troubling situation, in which we often attempt to do more with the situation than we really had to do, with the result being even a worse outcome than we could have imagined. Instead of following the dictum that Miller promulgated, and simply attempting to get out of trouble, we attempt to use an overly complex solution to eradicate the issue when all that was needed was a much simpler and more straightforward solution that held a higher probability for achieving success. Why do you need to run as fast as you can over a rough and dangerous terrain, if you have the option to walk over a smoothly paved sidewalk and still get to where you need to be without risk of injury or encountering further problems? This was what Miller was saying. Why are these golfers making it more difficult than it has to be, especially with a game that already has considerable difficulty built into it? This also applies to many managerial situations within healthcare. Why do many individuals make it more difficult for themselves by attempting to implement arcane and impractical solutions that often lead them over rough and dangerous terrain, when they could simply get out of their trouble using much simpler solutions?  Probably part of the answer lies in the misconception that most of us hold: If a difficult problem exists, we must always attempt to eradicate the problem with a solution that is equally difficult. This misconception often leads us to myopically only look for complex solutions with higher probabilities for failure, when often the first step is simply to use a straightforward strategy to "get out of trouble."

Even Albert Einstein stated " a theory should be simple but not more so," implying that we need to address the issue at hand in a practical manner and not get involved in unnecessarily convoluted theoretical concepts that can ultimately obfuscate what we are attempting to address and explain.   

Think of a few scenarios here that often exist in health care facilities and their management in what often violate what I will refer to as the "Johnny Miller Principle of Management." Remember, we often have to manage the situation, and no single individual can manage the totality of any facility or organization at any single point in time. Yet, what often happens with many administrators, executive directors, chief operating officers, and yes, even the President of the United States? They often attempt to tackle a problem that may be relegated to a particular situation by addressing not just the problem, but even moving beyond the boundaries of the problem. In so doing they will frequently dilute the solution to the problem and even create problems in other areas of the organization that may not have existed before their attempt to reorganize and become too expansive in their problem-solving efforts. What happened?  Miller's Principle was violated. When you are in trouble, the first thing you should do is get out of trouble. If X is the problem, simply address X, the problem, and get out of trouble. There is no need to change Q, R, and S if they are 1) not part of the problem, and 2) if doing so increases the probability for further problems.

Think about the issue of what is often referred to as "sunk costs." This is where a cost exists and cannot realize any return on the cost. Yet a common psychological heuristic that exists among individuals is that if any investment has been made, and you suffered a loss, continue to invest since you have already committed yourself. However, this is not rational. If your cost has been incurred it is lost. Yet we often feel compelled to continue to chase an illusory loss that we feel can be resurrected is a Lazarusian manner. If an investment is a bad investment the best managerial strategy is to prevent any future losses and move on. Again, Miller's Principle-when you are in trouble, the first thing you do is get out of trouble, not compound it and make it worse.               

I have witnessed individuals attempt to remedy health care deficiencies that surveyors have found to exist. Here is another issue that is frequently found to violate Miller's Principle. In addressing the problem, what often entails is the thinking that more words and more remedies often implies more solution(s) to the problems that they are attempting to correct and have been found in violation of federal and/or state regulations. Often this same type of poor logic not only exists among the managerial and administrative staff of a health care facility, but also among the regulatory personnel as well. "If you get into trouble, the first thing you do is get out of trouble." If A is the problem, then address A. If A and B are the problem, then address each one. No more or no less is needed. Too little and you are not solving the problem and getting out of trouble. However, often the problem is with too much. If you do too much you are frequently diluting your solution toward the problem at hand, and furthermore, you often are mathematically increasing the probability of more problems that will ultimately 1) fail to solve the original issue, and 2) make for a refractory issue in which the solutions add further problems, which in turn can lead you to even greater problems. To use a golfing analogy that Miller would probably agree with, if you are in the rough, do not think about aiming for a green surrounded by water and sand. Get out of the rough first (the current trouble you face) and get into the fairway. Then you can plan your next shot, or managerially speaking, you next plan of action. "When you are in trouble, the first thing you do is get out of trouble."

Health care facilities will often attempt to increase their income by taking residents with higher acuity to enhance reimbursement, especially rehabilitative reimbursement through Medicare. However, what if you extend your services beyond the resources you have available to serve the clients within your health care facility? Again, it would be extremely idealistic to say that money is not a concern. Money is a concern regarding whether you are a for-profit or not-for-profit organization. However, attempting to increase the patient or resident-base beyond your resources available to further enhance your net income will not only be counter-productive to the clients you are servicing, but to your organization as well. How do you solve the problem? You could get the resources you need to appropriately service your clientele. If this is not tenable, reduce the type and kind of clients you service that will allow you to safely and effectively address the situation.  "When you are in trouble, the first thing you do is get out of trouble." 

Let me provide one last example. Many individuals often want and need to mathematically quantify problems in management. However, often their attempt to find and quantify problems can lead to more problems. For sure, one needs to look at their income statement for the month and see if a problem exists.  Furthermore, using a T-test to examine the statistical effectiveness of one group to another may be very important for addressing and quantitatively analyzing a problem as well. However, often individuals will think if one measurement is good, then each additional measurement that I add will further help to solve a problem. In today's world management is often based on the many quantitative tools that are available. They think quantity leads to quality. Many also think these tools aid magically in addressing the problem. They still need to be interpreted and used correctly. Furthermore, frequently there is the problem with over-management by overuse of these tools. Often if one tool does show a problem it is often common to use another tool to help triangulate the issue and provide greater validity. However, to continue to use one measurement tool after another, all showing a problem exists is redundant, and you are then left with attempting to correct the results of each tool, which does not necessarily correct the problem and is an incredible waste of time, not to mention an inappropriate use of needed resources. The measuring devices, whether it is a cash flow statement, and correlational measurement, or a forecasted regression analysis, which are means that should be used judicious to find and correct the desired end or goal have now become the goal in themselves.  Here again, if a tool or even a few tools have found and confirmed an problem, address the problem and get out of trouble. There is no need to compound your tool usage and continue to waste time, money and valuable resources just to advance the pursuit of an intellectual counting exercise. "When you are in trouble [and trouble has been identified], the first thing you do is get out of trouble." If the managerial analogy of your trouble is that you are just off the green and are terrible pitching up safely unto the green, use your putter and safely get it on the green. Then plan your next shot if you need to at that point. 

Using golf as a strategic analogy for thinking about managerial problems is highly beneficial. Good golfers are always managing the situation over the entire course. As Bobby Jones stated, the success of any golfer exists within a space of about six inches between both ears. That is because golf is strategic and is based on sound management of the course. They do not plan to manage the entire course all at once. Their management is situationally based, predicated on each shot that they take over the 18 holes. Jones' statement however can also apply to all management. Furthermore, successful management of the course often means that you avoid foolish errors and employ Miller's Principle-The first thing you do when you get into trouble is get out of trouble. The course however does not just have to be a golf course, but the business, facility or organization can also be viewed as a competitive course environment as well.       

Management in general and managing health care facilities in particular are quite similar to managing the golf course. Attempting to manage an entire facility or organization at a single point in time will lead to failure. Each management decision is based on the situation that one finds oneself in and all decisions that have been made up to that point in time. Therefore, next time you encounter a problem think about the Johnny Miller Principle: "The first thing you do when you get into trouble is get out of trouble." It is simple, clear and apparently obvious. However, how often does one violate the principle in attempting to manage their health care organization? Thank you Johnny Miller for giving impetus to the introduction of a principle that can have an important managerial impact for so many if they adhere to just a few simple words.                

Pump Iron to Help That Aging Pouch
February 5, 2015 1:50 PM by Brian Garavaglia

Aging is often accompanied by the dreaded sagging midsection. This is not an evitable consequence of aging.  It typically happens due to engaging in more sedentary activity. Unfortunately, as we age, the tendency to become less active not only has consequences for the abdominal area, but for the entire body. Add to this the tendency for many Americans to eat poorly and it is not so much age, but poor lifestyle habits that often lead to increased girth and sagging muscle tone.

Most recommendations for addressing excess weight and abdominal obesity have emphasized aerobic forms of activity, such as walking, running, using a treadmill or exercising on an elliptical machine. This type of exercise provides continuous movement and emphasizes slow twitch muscles that are more dependent on higher levels of oxygen, placing greater focus on the heart and respiratory system. Also, due to the continuous movement, it typically burns greater levels of calories during the time the exercise is done. However, in a study that was conducted at Harvard University's School of Public Health, the importance of weight training for older individuals may be at least equaling important in controlling one's abdominal girth.

The study however used only males, so whether the same results apply to females can only be hypothesized. The study at the Harvard School of Public Health used 10,500 volunteers, all men who were 40 years old and older. The study participants all had varying levels of body mass indexes. The individuals were monitored for 12 years, from 1996 to 2008. The study participants demonstrated important benefits from weight lifting. Although the study participants that increased their aerobic activity also decreased their waistline measurements, those that had the greatest levels of success were those that used both aerobic exercise and weight training. Individuals who increased their aerobic exercise duration and intensity attained a 0.33 cm reduction in their waistline compared to a reduction of 0.67 cm found among those that used both aerobic and weight training. The study's author Frank Hu, professor of nutrition and epidemiology at Harvard's School of Public Health states, "This study underscores the importance of weight training in reducing abdominal obesity, especially among the elderly ... to maintain a healthy weight and waistline, it is critical to incorporate weight training with aerobic exercise."

Weight training is especially important for older adults in helping them ward off the dreaded belly bulge due to the enhancement of muscle tone in the abdominal area as well as in other areas of the body. With age, sarcopenia, or significant muscle mass loss can not only be potentially aesthetically unsightly  as it relates to midsection distention, but it can also be accompanied by other problems such as back pain, leg weakness and falls, all that can be potentially damaging to one's health and longevity. 

Another benefit that needs to be addressed here is that although aerobic activity, due to its continuous nature, tends to burn more calories over the time the exercise is done, there is a precipitous return to one's resting metabolic rate over the next couple of hours after the completion of the exercise. However, with weight training, the more anaerobic nature of the exercise leads to a higher metabolic rate for up to 24 hours after the weight training session. Therefore calorie expenditure continues for a period of time well after the weight training is discontinued. Moreover, muscle is a highly metabolically active tissue, and as muscle growth is added through weight training, which happens among older adults as well, one's resting metabolic rate is increased, leading to a greater amount of calories burned over a 24 hour time period. This all leads potentially to less fat around the midsection and strong muscle tone within that area as well.  

Frequently, the thought of weight training for older adults is counterintuitive. Many think it is only something that should be untaken by younger individuals and athletes. It is also thought that weight training can only enhance muscle growth among younger individuals, which is a very inaccurate misconception. Finally, many think that the flabby and pouching midsection is an inevitable part of aging. In fact, aging is often used as the scapegoat for justifying one's increasing weight, flabby midsections, and increasingly sedentary forms of activity that often prevent adequate exercise and caloric expenditures. However, as has already been stated, these are not natural or even inevitable facets of aging. They are facets of unhealthy lifestyle habits that we have come to adopt. As the Harvard School of Public Health study has shown, individuals that add weight training to their lifestyle activities can appreciably benefit their midsections. Furthermore, weight training in addition to aerobic activity helps to play a multifaceted role on the overall health of the individual. Overcoming some of the major misconceptions regarding age that often lead individuals to accept complacency and sedentary activities is probably the biggest obstacle that needs to be addressed. Therefore, if you want to stay strong, stay healthy, and stay slim, start moving and also add some weight lifting exercises to your daily regime to not only maintain muscle tone in those arms, shoulders and chest, but to enhance your waistline as well.   


Pumping Iron Gives You a More Sculptured Waistline than Engaging in Aerobics (Dec 26, 2014).  Empire State Tribune. 

What Needs to be Done to Improve Nursing Home Care
January 28, 2015 9:30 AM by Brian Garavaglia

Over two decades ago the report from the Institute of Medicine (IoM) led the way for monumental changes to take place within the nursing home industry. The report of the IoM basically stated that nursing homes needed significant reform and that it was an industry that was loosely regulated, potentially compromising the lives of many who reside within our country's nursing homes. What subsequently followed was a monolithic effort to reform the nursing home industry. Over 28 years has passed since the report came out leading to widespread regulatory changes within the nursing home industry. However, nearly three decades later, we are still left with an industry that continues to face significant problems. Although many do not question that nursing homes have improved, one may nevertheless question that the changes that have ensued have really not been as monumental as was initially planned. In 1987, when the Nursing Home Reform Act or OBRA was introduced, most would have foresaw that in approximately three decades hence, major changes would have resulted with many of the problems that plagued nursing homes then failing to exist as one looked down the road into the new millennium. However, in reality, although some improvements have come to fruition, in reality many of the same problems exist. Furthermore, other problems have also become quite prominent that may have even left the industry in even greater disarray. I would like to take a look at some of these major issues and briefly address each, as well as what needs to be done to correct the issues that are currently found in our country's nursing care centers.

The Primacy of Economics 
A major issue driving many of the other issues found in nursing homes is the economic primacy that surrounds care. Peterman and Williams (2006) have pointed out that many major companies have faced issues of bankruptcy due to the increasing loss of revenue. With the advent in particular of assisted living facilities (ALFs), many individuals who would have once been admitted to nursing homes are now placed within ALF environments. The assisted living environment has cut into the financial backbone of the nursing home industry, leaving it with a lower occupancy rate and with it, less money to take care of an increasingly older and sicker population.

Another major cost-containment reform was the passage of the Balanced Budget Act of 1997 (BBA). Prior to then the payment system was retrospective and nursing homes were paid in full for care provided to qualified Medicare residents. With the passage of the BBA that changed. Payment went to a prospective payment system, similar to DRG's that were instituted in hospitals a decade earlier.  Now payments were based on specific diagnostic and rehabilitative codes that were associated with a particular reimbursement level. This made payment more unwieldy and typically what is billed for and what is authorized by Medicare left many nursing homes short of the actual cost of services rendered (

Furthermore, most payments received by nursing homes for services were paid for through Medicaid. Medicaid, a medical policy initially put in place for the indigent, has come to be responsible for approximately 70 percent of the remuneration found within the nursing home industry. However, Medicaid has notoriously paid low amounts, often far below the cost of services for the resident. In addition, Medicaid has often fluctuated upwards and downwards without much notice, leaving many nursing care facilities at the whim of what Medicaid will eventually pay (Peterman and Williams, 2006). Moreover, with many assisted living facilities admitting many older adults, who then pay for their assisted living services through their own cash savings, this has left the nursing home environment admitting many who only are able to pay with Medicaid, which as previously stated often pays far below the cost of services that are rendered to an older and sicker clientele that needs much more continuous and ever-increasing levels of invasive and professionalized care. So here is a major quandary. Assisted living services are often getting considerable cash income and have an environment with low overhead costs. Conversely, nursing homes are taking on an older and more infirm population and are (1) having to work within a climate in which Medicare reimbursement is becoming more parsimonious, and (2) Medicaid, the prevailing level of payment, is often paying an unrealistically low level for service costs that frequently far exceed the Medicaid payment rendered to the nursing home.  What do nursing care facilities do to address this dilemma?

The largest cost to the nursing care environment is staffing. Approximately 70 percent of the operational cost is due to staffing. Therefore, the most common and reflexive knee-jerk response for nursing home companies in reducing operational costs is to reduce staff. In addition, having to recruit better personnel is often difficult if one is attempting to cut costs in staffing by reducing the number of personnel as well as through offering lower wages to professional staff. This is not conducive to nursing home environments that are witnessing higher levels of acuity. Recruiting professionals with important skills that address the myriad of needs that are now found in the nursing home environment require offering workers competitive wages and having an appropriate number of skilled professionals working all shifts within the nursing facility.  This however is not found among most nursing care facilities.

With a lower nursing home census coupled with further reductions in private pay, Medicare reimbursement, and an increasing dependence on a lower pay funding source (Medicaid), nursing homes are streamlining operational budgets, especially through reduced staffing and minimizing the number of more qualified skilled nursing personnel.  This all too common strategy toward addressing these pervasive issues has often led to compromised levels of care (

Here is the irony to the above stated issue. During an era when nursing home reform has emphasized the need for adequate staffing requirements, appropriate staffing often fails to exist. Furthermore, at the same time that the federal and state levels of government have continued their adjuration for improved staffing, they have also failed to maintain adequate funding to nursing homes. Reimbursement has not kept pace with 1) the increasingly higher level of acuity found in nursing homes; 2) the need to competitively recruit highly skilled personnel that often gravitate toward higher paying hospital environments; 3) the increasingly higher rates of inflation in many areas of health care services; and 4) the unrealistic assumptions found within Medicaid payments and bundled packaging of Medicare that often encourages extreme streamlining with the thought of fostering greater efficiency when in reality it often encourages reduced caregivers and an elimination of important services that could be provided if funding was available.

Moreover, recently the Centers for Medicare and Medicaid have added penalties to hospitals that receive residents back within a 30 day window, and these same penalties will also be introduced into the long-term care setting starting in 2018 (Luke, 2014; Rau, 2014). Many hospitals have started working with nursing homes to share in the penalties for residents returning within a 30 day period that are now instituted. Here again, however, this often will take further money away from treating many individuals that often have very severe conditions that may lead to unavoidable returns to the hospital. Having this type of policy could 1) potentially lead to many individuals staying within nursing care settings too long during periods of acute exacerbations, further jeopardizing their lives when they should return to the hospital due to fears that they may be financially penalized by CMS, and 2) Medicare regulators often paying excessive attention to financial bottom lines that are unrealistically promulgating policies that may do more harm than good (    

Other Problems That Continue to Exist   
The guardian of nursing home quality is the survey process. These surveys are typically completed by state inspectors, although at times federal surveyors will conduct surveys as well. The survey process was instituted to assure compliance with the federal regulatory requirements. Surveys are done annually, conducted within a nine-to-15 month window. Complaints surveys are also done when complaints are received on nursing homes. Although surveys create a monitoring device that oversees nursing home compliance, it is far from a process that has worked well. First, many surveyors often have never worked within long-term care themselves. Many become surveyors after a short period of training and subsequently are then placed into an environment in which many have never had any firsthand experience with as direct-care workers and caregivers.

Furthermore, the survey process, instead of being facilitative toward a common goal of improving the care of the nursing home resident, is often adversarial. The nursing care facility and its staff and the survey staff are often viewed as being on opposing sides. Unfortunately, the survey process, which could be a very productive process if it was developed for both parties to cohere and work together has devolved into a divisive interaction. In fact, surveyors often state that they cannot provide information in assisting the facility with their plan of correction even though they are well aware what they would like to find in a plan of correction for it to be accepted. 

The survey process also continues to notoriously be a very subjective process. Far from being objective and guided by objective indicators, the surveyors often use their own perspectives to determine whether they should establish that a violation does exists and whether a citation should be levied against the facility. The surveyors are still guided by federal regulations that they cite, but their own unique perspectives help to further determine whether a regulatory violation exists. Different survey teams found in different areas and different states often give different numbers and levels of violations. Therefore, the survey process is far from objective and standardized (Ornstein & Groeger, 2012).

Another issue that also needs to be addressed is the issue of ownership. It is well-established that for-profit nursing care facilities often have higher rates of citations and lower staffing ratios. Furthermore, the Government Accountability Office (GAO) has found that for-profit facilities were demonstrably poorer performers nationally as compared to not-for-profit facilities (Centers for Medicare and Medicaid Advocacy). What is often more disconcerting is that many nursing facilities have now been purchased by larger equity firms whose expressed goal is to focus on the profit incentive. In fact, for-profit facilities are now the most common form of nursing care facilities and most of these facilities are now becoming co-opted by large equity firms with individuals who often have very little, if any experience, in health care. 

Private equity firms have become a common type of group that has come to play a significant role in American business. Their goal is to invest and make a profit. However, this form of business endeavor, using a traditional business model with individuals who have little knowledge of the long-term care industry often leads to problems that have continued to haunt the nursing home environment. Maintaining cost-control is very important. An important problem in health care today is attempting to curtail the inflationary environment that is found in health care. 

However, attempting to make profit at the expense of cutting costs within a long-term care environment that has become increasingly more complex and diverse in the types of conditions and clientele that they treat is a problem that continues to plague nursing homes. 

Even more problematic is that the ownership that often is insisting on instituting many of the cost-cutting maneuvers are oblivious toward understanding how their decisions are having or will have a negative impact on the clientele that they are ultimately suppose to be servicing. They are unable to disentangle their concern of profit margins from the nursing home resident. Profits and residents are compiled together as a form of capital that needs to be invested in and monitored for their returns. This kind of attitude has led to an instrumentalism that conceives of the nursing home resident as a type of capital investment.       

One final thing should be mentioned before we leave this topic. It has been mentioned that the economic primacy of the nursing home environment is the prevailing issue that often foments many of the problems that have been mentioned. As has already been mentioned, Medicare and Medicaid payments have not kept up with the inflationary health care costs found in long-term care. In addition, many nursing homes have now lost further economic resources due to the assisted living facility industry admitting many individuals who would have been formerly admitted to nursing home environments. In addition to this loss in reimbursement and loss of resident population, many nursing care facilities have further been plagued by civil monetary penalties (CMP) that the government places on nursing homes that have poor compliance. However, the problem with using a monetary penalty levied against nursing homes is that a punitive financial measure is ultimately harming the residents that it is supposedly intended to help. There is an inherent contradiction in this logic of using CMPs as a corrective action. Since the government is stating we will not provide financial payment to a facility as a penalty for not providing appropriate care, and subsequently since residents are inclusive in that nursing home environment that is penalized, the residents are ultimately the one's that a further harmed, not just by the facility's noncompliance in care, but also through taking money away from the facility that would go toward allocating appropriate provisions and care to nursing home residents.

Although there has been some appreciable advances in nursing home care since the advent of the Omnibus reconciliation Act or OBRA of 1987 that created widespread nursing home reform, to think that the nursing home industry has made quantum leaps since OBRA was introduced would be to delude ourselves. In reality, there has been improvement in some areas. In other areas the improvement has been negligible at best. Moreover, when one examines the landscape in totality, the level of improvement from the middle part of the 1980s to now is far from what one would have hoped for given the high aspirations that were often associated with the nursing home reform movement. This being stated, we should not be dismissive toward the small changes that have occurred, but look at them realistically and use them to build further and more progressive changes. However, as has been detailed in this paper, we have to move beyond the current environment that exists within long-term care. A paradigm shift needs to be instituted. This paradigm shift has to be a true paradigm shift, not a fallacious shift as has been witnessed over the past 30 years. A true paradigm shift will see surveyors and nursing home staff working collaboratively and not at disparate ends. A true paradigm shift will hold ownership increasingly responsible for many of their decisions. A true paradigm shift will focus on enhancing resident care and resident's lives within nursing homes as an end in itself and not associate the resident as a type of capital. A true paradigm shift will not continue to add layer upon layer of regulations, which ultimately leads to nursing homes being more concerned with the regulatory environment and not the resident who becomes lost in the regulatory labyrinth. Finally, a true paradigm shift will not institute punitive measures and say they are an attempt to enhance compliance and better resident care when in fact they work quite to the contrary. What was mentioned in this paper was by far not an all-inclusive list of problems and remedies. However, enough has been stated at this time to allow those who read this to assimilate and ponder the information as well as being an initial step toward helping to stimulate discussion on how to enhance an industry that continues to need much remediation.          


Centers for Medicare and Medicaid Advocacy (n.d.).  Non-Profit vs. For-Profit Nursing Homes: Is there a Difference in Care?

ElderLawAnswers (n.d.).  How Bad Off Is the Nursing Home Industry?

Luke, J. (2014).  SNF readmission penalties announced: Is your facility ready?  Californial Association of Long-Term Care Medicine.

The Nursing Home Crisis: Public Policy Gone Awry No. 140.  Americans For Democratic Action.

Peterman, N. A. & Williams, C. B. (2006).  Skilled Nursing Home Facilities: The Challenge of the 21st Century.  American Bankruptcy Institute Journal.   

Ornstein, C. & Groeger, L. (2012).  What we found using nursing home inspect.  ProPublica.   


Rau, J. (2014).  Medicare Fines 2,610 Hospitals In Third Round Of Readmission Penalties.  Kaiser Health News.

A Simple Piece of String Can Enhance Your Life
December 8, 2014 10:52 AM by Brian Garavaglia

Living longer. Many individuals are often attempting to find some fountain of youth that can enhance their lives. Commercials and advertisements abound with supposed remedies that will increase one's life. Yet, a very simple technique that dentists have been advocating for years can be an important enhancement for one's longevity. Research has been finding that oral care is very important for not only warding off diseases of the mouth, but also other more systemic ailments. Furthermore, gum health and regular flossing of one's teeth can be an incredibly important lifestyle feature that can be an important preventative form of health care as well as a technique that can be used to enhance one's life.

For years dentists have advanced the importance of using that simple piece of string to mechanically remove debris that settles in between teeth and at the gum line. The gums often become inflamed due to bacterial infections, many of which go unnoticed. Food particles that remain between teeth and in the gum lines can further produce a very good growth environment for bacteria. Bacteria within the gums does not just stay within the oral cavity, but further migrates to other areas of the body. In particular, recent research has paid particular attention to how poor oral care and infections in the oral cavity can contribute to heart disease. In addition, chronic inflammation of the gums due to bacterial infections can lead to further health issues as the bacteria moves to other areas of the body. These continuous levels of infection within the gums and oral cavity can continue to lead an assault on the body that reduces one's life expectancy. 

Many simple solutions often fall far short of their stated results. However, a simple piece of string or dental floss used regularly appears to be one of those important simple, yet profoundly impactful lifestyle habits that can hold significant consequences for a person's longevity. Many individuals often have minimized the importance of oral care in general, and flossing in particular, as part of a healthy lifestyle behavioral intervention that can enhance one's health and longevity. In fact, it has been estimated that sound oral health can add approximately 1.5 to 6 years to one's longevity. 

Most of the older adult population fails to recognize the importance of flossing. Moreover, most of the older adult population also show signs of gum disease. This is problematic since not only is gum disease the leading cause of tooth loss, it is evidence of a constant and unabated infection that exists. A continuous level of bacterial buildup infecting the body can have a pervasive impact on one's health. That can ultimately lead to more health issues and premature death. Yet, a very simple mechanical measure of flossing daily can provide important dividends for one's overall health. 

As problematic as gum infections are in the mainstream population, among the institutional population it is even a greater epidemic issue. Among those older adults within nursing homes, dental hygiene is often overlooked by caregivers. A large portion of the nursing home population not only fails to receive adequate professional dental care, but they are also failing to get the appropriate level of daily care that can lead to not only good dental and periodontal health, but also assist in forestalling greater levels of infection, compromised health, and possibly unnecessary hospitalization. Again, much of the inadequate dental care provided to older adults is frequently due to the lack of knowledge among the staff regarding the importance of oral and dental health to the overall systemic health of the person.

Given the growing level of research on dental health and its connection to the overall health of the person, it is becoming increasingly apparent that aging in a healthy manner, compressing overall morbidity as we age, as well as increasing our longevity is dependent upon paying greater attention to our dental care, and in particular being sensitive to our gum health and our need for proper flossing to assist in this area. It appears that individuals can often be dismissive about the importance of flossing, particularly due to it being a very simplistic modality which intuitively does not seem to fit with the complexity that we often seek for increasing health and longevity. Yet, this very simple dental procedure, if used daily, can aid in gum health, and aid in the general health of the person, which in turn can potentially add years to one's life.     


Stibich, M (2014).  Simple steps to increase your life expectancy.

Adult dental health: Healthy aging (2014).

Finding the Problem: Avoiding the Misguided Search
October 30, 2014 11:11 AM by Brian Garavaglia

One of the buzzwords in long-term care is looking for the "root-cause" for various problems that arise. Many of these "root-cause" searches are often based on resident care. Others are often facility-based, especially related to financial information, staffing, and general supplies and facility maintenance. However, many of these supposed "root-cause" analyses often fall far short of ever finding the supposed cause that they were set to initially determine. In fact, many frequently become side-tracked and move into other areas, compromising their focus on the initial target. What follows is a brief overview of a few major issues that lead to problems in long-term care never being discovered and subsequently addressed. 

Failure to Understand and Find the True Problem

To be able to address a problem, the problem has to be clearly defined. It is common to find and address a problem. However, whether it is truly the problem that is leading to the issue is a totally different story. The successful amelioration of a problem is incumbent upon defining the appropriate problem. All too often attempting to isolate what the true problem is provides considerable difficulty. The reason for this is that often there are a number of potential issues that are closely related. Yet, each of these issues may have considerably different ramifications. However, without being able to isolate the specific issue or problem that leads to the particular health care consequence, the person is left chasing rainbows. 

Finding the specific issue and then defining the problem is much more difficult that it appears. This author has provided simple, single paragraph problems to his classes in which they were instructed to find and isolate the problem that brought about a particular scenario. When the problem was imbedded with other superfluous information most individuals often failed to identify and isolate the specific problem or issue. Many targeted the consequence, and not the problem. Furthermore, many others often would isolate the superfluous issues that were not even close to being related to the true problem. Without any training, isolating a problem that is leading to the consequence of a particular situation is quite difficult. Yet, in health care situations, adjurations are often made for health care professionals to undertake this task as if it is easy or as if long-term care professionals and administrators are well-practiced and proficient at this task. Many of these individuals are often surprised to find out how a seemingly very simple problem in a single paragraph is unable to be clearly isolated and articulated. Therefore, given these results it should be no surprise to find that many individuals often fail to find and express the true problem in real-life situations when these problems are often much more intertwined with a myriad of other closely aligned, yet different problems, all leading to very different consequences.  

The Illusion of Cause 

Cause if often referred to as the goal in examining problems faced within any health care area, including long-term care. However, the image of a person often finding and isolating a single cause, as is often misleadingly made during such techniques commonly referred to as "root-cause" analysis, leads to an impression that there is often a single root cause that can be found for everything. This is a residual aspect of the Platonic vertical process of thinking, which asserts if you dig deep enough you will always find the quiddity for anything. However, this is far from being the reality that exists. A single "root-cause" is often not a reality, since often there is frequently more than one antecedent that can lead to a single cause. Furthermore, a single antecedent can lead to more than one consequence. Moreover, often the best that we can find is not a cause but a number of correlations, often failing to understand the distinction between causative and correlational findings. As one can see, something that is often conveyed as being a facile assignment of finding a problem is quite complex and needs considerable training. Far from what most higher level managers or executives assume when they mandate these problem-solving assignments onto their staff, this assignment, looking for a "root-cause" or any type of cause, is far from manageable for most individuals who fail to have proper training in this area, including most upper level managers.

Moreover, think of a simple cause that you do find. A simple cause (C) will often have many subcomponents involved (C1...........Ca). Take for instance something apparently simple such as turning on a light. What causes the light to be turned on (C)? The person flipping the electrical switch? However, is that the cause? Yes, but not the sole cause. What about the switch making proper contact? What about having a proper electrical conduit? What about the need from proper electrical wiring? What about paying the electrical bill to maintain electricity coming into the home so the switch can activate the process? Also, what if all of this is in place and there is no bulb within the light socket? As one can see, C (turning on the light switch to turn on the light) actually subsumes a number of other features that also are part of the causative process.

What about a person that has a medical issue such as an ischemic cardiac incident? Apparently, since it is an ischemic issue that should be the cause (C = ischemia). Although that may be viewed as the proximal cause, could there be others. Could volumetric changes in the blood and viscosity also be issues that are even more proximal? What about the inadequate nature of certain clotting factors? What about continuous lack of mobility leading to thrombotic features to form?  Could a poor diet of fried food and saturated fats be causative? Could the lack of exercise have led to this issue? Could heavy smoking, along with a generally unhealthy and sedentary lifestyle have been the true ultimate or root cause? Here again, we see a number of causative factors that often are inclusive in what many individuals have assumed is the apparent cause. Is what was thought to be the apparent cause (ischemia) just the most recent and proximal of many other linkages that were more distally causative? Look at the complexity that just in these brief few paragraphs have been brought to the attention of the reader. And yet, when many long-term care personnel are instructed to find root causes, personnel who have often little if any training in this area, the assumption is that they will assuredly find the root cause. What is even more disconcerting is that those that do the investigation, frequently in a cursory manner, often come away with a false self-confidence in their results, thinking that without exception they have found the elusive, quintessential factor that led to the problem.  

So What are the Consequences?

Problems are an endemic part of life. Finding the reason for their existence and attempting to solve these problems are an unending quandary that we face as part of life. Problems in long-term health care situations are no different? Whether it is attempting to find the reason behind unanticipated hospital admissions, or why average staffing ratios are running higher than in other facilities, or even why family members are selecting other facilities over your facility, many mistakes are often made toward attempting to find and solve important problems. 

Thinking that one will always find the so-called "root-cause" is one major misattribution. Many problems quite simply will never manifest a clear "root." Furthermore, assuming that there is only a single cause is also quite problematic in itself. Even though many executives are adjuring their staff to "find the problem," they themselves, referring to the "problem" in its singular form are framing the issue in such a manner that those that will approach the problem will think that there is a single cause. Even the concept of "root-cause analysis" often conveys that a singular cause can be found and is always there to be apprehended. 

Furthermore, another issue that has been mentioned is that individuals will often approach problems in health care without a clear understanding of what the problem is. Failing to clearly isolate and identify the problem will provide a totally misguided approach to solving any particular problem. Regardless of the assiduous nature of your investigatory endeavor, you could painstakingly follow a wonderfully deductive and logical approach that achieves a perfectively sensible result and solution. Yet, if you start off with the wrong problem, the solution will nevertheless be incorrect. For instance, consider the following:

  • All dogs have three legs,
  • Buck is a dog,
  • Therefore, Buck has three legs

Is the syllogism above logically correct? Yes, but is it true since it started out with an incorrect major premise (All dogs have three legs)? No, it is absolutely not true. Even though it is deductively valid, following the steps to achieve a logical conclusion, starting out with an incorrect premise still leaves us with a valid conclusion but one that is not true-all dogs do not have three legs. The same exists for those that start off by defining the problem correctly. A valid conclusion may be deductively found, but it may have nothing to do with the correct problem. 

Thinking that solving problems correctly in long-term care can be achieved by anyone and just by using a little hard work is a very misguided assumption. Problem solving is something that needs considerable practice and training. All too often, problem solving, not just in long-term care but in all health care is approached with an ill-conceived, loosely structured, and even a somewhat cavalier attitude. However, hopefully after reading this paper, individuals will see that problems, finding them and solving them are often far more complicated than many think and that it often entails a considerable level of training and practice to become proficient at such a practice. Understanding the complexity of problem solving and consistently practicing your skills and avoiding some of the common errors that have been discussed will ultimately lead to addressing many concerns that arise within long-term care in a more insight and productive manner.                       

Can Jellyfish Hold the Secret to the Fountain of Youth?
October 22, 2014 2:06 PM by Brian Garavaglia
The fountain of youth and eternal life has been something that has been sought and spoken about for a number of years. We still often hear the term, "anti-aging" used in reference to various types of supplements that are frequently advertised, as if using these supposed products will reverse aging or prevent any further aging in the person.  However, some recent research has provided a level of authenticity to claims of age-enhancement. 

However, who would have thought that the answer to some of these questions may be found in the jellyfish. One researcher thinks that these marine animals may be able to provide important contributions to our knowledge regarding aging. These gelatinous, strange-looking aquatic forms of life are now being looked at for holding some possible answers to the questions for life-enhancement. 

A professor at Kyoto University in Japan, who has been studying jellyfish for over three decades, feels that these creatures may hold important clues toward potentially enhancing human life expectancy. Shin Kubota has been studying the jellyfish since 1979. According to Kubota, one type of jellyfish has a particular quality to regenerate itself and take on a level of immortality. The type of jellyfish that has this potential is referred to as the scarlet jellyfish. He stated that this species of jellyfish have the ability to "rejuvenate" themselves.  Furthermore, he has also noted that there are two other species of jellyfish that also hold this potential. 

According to Kubota, the adult scarlet jellyfish, referred to as a medusa, when injured, goes to the ocean floor. However, instead of dying, it goes through a process of rejuvenation.  It goes back into an infant state of development referred to as a polyp. The polyp continues to develop back into the adult medusa.  Kubota, in his laboratory work with this species of jellyfish has been able to successfully make the jellyfish rejuvenate 12 times in his laboratory studies.     

Kubota states that genetically the jellyfish and humans are not that different. Therefore, he is hopeful that the studies will result in finding out further information about this regenerative ability found in the scarlet jellyfish that may be able to be applied to human beings, which may ultimately help enhance their longevity. However, the research is still in its early stages. However, it does lend a level of excitement, witnessing one living species that may have some level of immortal ability being able to possibly lend some secrets that may help human beings enhance the overall life expectancy as well.

One note of caution has to be mentioned. Kubota himself recognizes the possibilities that this research may hold for human development. However, at this time there is still much more research and many questions that need to be answered. Yet, there are some products that are currently being advertised as anti-aging or longevity enhancing products that are taking advantage of the scientific findings of the jellyfish research and marketing themselves has having "the chemical compound" that is found in jellyfish and that will enhance human longevity. So watch out for those products that are attempting to use scientific research, such as has been discussed here, and often misrepresenting that research as if it were definitive in an attempt to sell a product that has no proven standards.     


Said-Moorhouse, L. & Sealy, A. (2014, Aug 29). Does 'immortal' jellyfish have the secret to everlasting life? CNN World.

One Half of Commonly Prescribed Medications Increase Falls Among the Elderly
September 3, 2014 11:26 AM by Brian Garavaglia

The European Journal of Public Health has found some important news: Many medications prescribed to the elderly may potentially lead to more harm due to falls, which subsequently can lead to certain life-threatening injuries. It was found that one-half of the 20 most commonly prescribed medications that are used frequently among the older adult population increase the risk of falls. This is very sobering news since many of these medications may be needed for other health related conditions, yet the cost may be falls that could in fact lead to more serious issues than the initial conditions that the medication was prescribed for.

Among the most serious medications that contributed to the increased fall risk were painkilling medications and antidepressants as well as sedatives and hypnotic agents used for sleep. All of these medications have an impact upon the central nervous system. They can cause grogginess, lethargy, a lack of coordination, and a clouding of one's consciousness, all of which may greatly increase an older adult's likelihood of falls.   

The researchers analyzed data on nearly seven million Swedish elderly and they found 64,399 cases of falls that lead to hospitalizations that were contributed to by the use of medications that had fall-inducing effects. The researchers found that those that were taking opioid and antidepressant medications had more than twice the likelihood of experiencing an injury due to a fall as compared to those that did not take these medications. Opioids are powerful pain killing medications, such as codeine, morphine or Vicodin just to name a few. They are opiate or opiate derivatives that have can not only have a pronounced pain killing effect, but they also can have a powerful effect on a person's consciousness as well as well as leading to an unsteady gait. Antidepressant medications, prescribed for depression or anxiety, often can lead to anxiety or feeling jittery, lightheadedness, and an unsteady gait. These are just a few of the common side-effects that can be found among these medications. Furthermore, the likelihood for these side-effects, all of which can lead to greater likelihoods for falls, increases with age. Although older adult males and females who took opioid medications appeared to be equally likely to experience adverse side-effects leading to falls, older women who took antidepressants had approximately 75 percent greater likelihood of falls.  

There were some surprising medications that appeared to be correlated  with an increased risk for falls. Medications used to treat GERD, calcium, often used for bone health supplementation, Vitamin B12, frequently given at higher doses by way of injection by physicians, and certain non-opioid pain killing medications demonstrated an increased risk of falls that ranged from 15% to 75%. Diuretics, often referred to more colloquially as water pills and frequently prescribed for edema due to congestive heart disease also was found to increase the probability of falls        

It must be stated however that these were correlational findings.  In other words, this was not a cause-effect finding. It is often very difficult to differentiate between the falls being due to the affects of the medications or due to the underlying medical conditions of the elderly. However, as one physician stated, one needs to pay attention to symptoms caused by many drugs that can potentially lead to falls. Individuals, including the older adult's physician, have to be vigilant for such things as vertigo, drowsiness, motor movement impairment, muscular weakness and cognitive impairment.  

The likelihood for experiencing side-effects that may cause falls does not in itself mean that these medications are not justified for use in the elderly. What it does state is that the physician needs to always consider weighing the fall risk that is incurred versus the therapeutic value that the medication may have for helping the quality of life of the older adult.

Older adult's become more sensitive to the side-effects of almost all medications as they age. The medication's dosage levels are often not determined based on different adult age group variations. This in itself is problematic since different ages, based on changes in the biological organism's structure and function as we age also alter the pharmacokinetic effects of medications. Therefore, given this, one needs to make sure that individuals are judiciously followed and evaluated for adverse effects that may potentially lead to falls and offset any therapeutic value of using the drug.         


Kennedy, M. (2014/Aug).  Many Meds Taken by Seniors Can Raise Risk of Falls.  Medscape

New Study Examines Gait Speed as Being Related to Future Dementia
August 19, 2014 10:07 AM by Brian Garavaglia

Dementia is a prominent concern among the older adult population. As the elderly population continues to increase, the number of those with dementia also will increase in number. Recent research on dementia and cognitive impairment in the aging has targeted a new disorder and with it, a new symptom that may be related to the likelihood of acquiring dementia. 

A recently newly defined disorder found among older adults, referred to as motoric cognitive risk syndrome (MCR) is characterized by cognitive decline with motor-based symptoms. The disorder appears to be common in older adults. However, those that have the disorder also appear to be at greater risk of developing further cognitive impairment that leads to various forms of dementia, including Alzheimer's disease. In fact, those that developed MCR were approximately two times more likely to develop dementia. 

The current syndrome, motoric cognitive risk syndrome, is diagnosed by simple questions related to memory as well as measuring gait speed over a fixed distance. MCR is able to be diagnosed independent of cognitive tests. The group under study was composed of 26,802 older adults, with an average age of 71.6 years. Slightly more than half of the sample was women. There were 22 cohorts from 17 different countries that made up the sample. 

Gait speed was measured using a stop watch and measuring the fixed distance that one walks within a given period of time. The average or mean gait speed was 81.8 cm/s, which is slightly less than three feet traveled per second. Those who were one standard deviation below the average walking speed were viewed as slow walkers and therefore comprised motorically. 

The finding showed that those that were diagnosed with MCR had worse performance on all cognitive tests than those who were not diagnosed with MCR.  Those with MCR also had a higher prevalence of disease, especially vascular diseases. The diagnosis of Motoric Cognitive Risk Syndrome has appeared to be able to have important predictive value as well. As Dr. Joe Verghese, lead study author states, "You would expect that the people who actually have dementia but are being classified as MCR would meet dementia criteria pretty soon over the next 2 or 3 years, but if you take them out, that would suggest that MCR can predict beyond the initial few years and capture cases that are going to develop dementia more than 3 years out." 

The study emphasized the importance of gait speed as being an important predictor of future dementia. As Dr. Verghese states, gait speed is highly reliable and has been a very sound predictor of health outcomes. In addition, gait speed measurements are simple, highly accessible, and easily done in most health care settings. However, he also stated that it may not be the only, or even the strongest motor predictor of dementia. However, the research in this area has been limited up to this time.   

Given that predementia testing is often quite expensive and frequently not covered by insurances, simple and expensive forms of testing and diagnostic evaluations are often welcome. Although this study appears to shed some light on a new diagnosis that may be an important predementia diagnostic, as well as the use of simple and less expensive diagnostic assessments for anticipating future progression to dementia, the new syndrome and its concomitant diagnostics will probably not be fully embraced at this early level. Furthermore, more research will be need to be completed before one can provide greater assurance regarding the validity of this new diagnosis and whether it is truly an important predementia diagnostic that can enhance our ability toward slowing down the progression of dementia.

Furthermore, the study did not appear to address the cause and effect nature of the issue of motor decline as it relates to dementia. Is motor decline a sign of, or even cause, of impeding dementia, or is it a related effect of dementia, albeit incipient stage brain changes that may already be occurring due to the dementia process. Moreover, if a person stays active and maintains a better gait speed, will that reduce the likelihood of dementia? Finally, is MCR a diagnosis that is truly separate from the dementia diagnoses and by creating a new diagnostic category will it be useful for treatment intervention or is it just another label being attached to the elderly person?

Many of the above questions I feel still need to be answered before we enthusiastically embrace a new diagnostic category. For the most part, some of the discovery that motor involvement may be related to dementia is not a great surprise since many forms of dementia will demonstrate motor issues as the disease progresses due to further insult upon brain tissue. I feel that the main question that really is of concern here and that needs to have greater clarification is whether:

  1. maintaining enhanced gait speed through exercise will reduce the likelihood of future dementia
  2. whether the diagnosis of MCR will be useful so that successful intervention can be brought about that would ultimately prevent or slow down further neurological disease progression.    


Anderson, P. (2014, July).   Slow Gait, Cognitive Complaints Predict Cognitive Decline.  Medscape,





About this Blog

    Brian Garavaglia, PhD
    Occupation: Long-term care administrator
    Setting: Sterling Heights, Mich.
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