From Health and Fitness

Can Personality Affect Dementia Risk?

Your personality in high school may help predict your risk of dementia decades later.

Researchers reached this conclusion using a 150-item personality inventory given to a national sample of teenagers in 1960. The survey assessed character traits — sociability, calmness, empathy, maturity, conscientiousness, self-confidence and others — using scores ranging from low to high. For their study, in JAMA Psychiatry, scientists linked the scores of 82,232 of the test-takers to Medicare data on diagnoses of dementia from 2011 to 2013.

They found that high extroversion, an energetic disposition, calmness and maturity were associated with a lower risk of dementia an average of 54 years later, though the association did not hold for students with low socioeconomic status.

Calmness and maturity have been linked to lower levels of stress, which may help explain the association. Lower socioeconomic status, which often increases chronic stress, may negate the apparent benefits of those personality traits.

“The study was not set up to discern a causal link,” said the lead author, Benjamin P. Chapman, an associate professor of psychiatry at the University of Rochester. “Most likely these traits lead to all kinds of other things over 50 years that culminate in a diagnosis of dementia. We tried to rule out as many other factors as possible, but our findings are suggestive, and we don’t want to draw strong conclusions about causation.”

We Flew All the Way Here for This?

My partner’s ex-wife throws up roadblocks to seeing his two daughters when we go to visit them. It’s a two-hour flight, so it’s not a small thing to visit. But his ex occupies all the girls’ time when we’re there. They are in their early 20s and live on their own. They complain about how demanding their mother becomes when we’re in town. I am the mom of their two young half sisters. It’s important to us to foster good relationships among the siblings. Does it make sense to continue these trips when we see so little of the girls? (It’s hard for them to get time off from work to visit us.)

STEPMOM

Forgive me, but it seems implausible that these independent women can’t break free of their mother to spend time with your family after you’ve flown into town expressly to visit them. Are you sure they want to?

I don’t doubt their mother may wield guilt like a cudgel depending on the circumstances of her relationship with your partner. But her daughters are adult women, not prisoners at a federal penitentiary. Maybe they’re using their mother as an excuse.

Before you book your next trip, have your partner ask his daughters when they will be free to meet. That should help you gauge their interest. It may also be useful for your partner to speak privately with his daughters about how much he wants to see them and whether they have any misgivings about the divorce or your new family.

It’s possible they simply have to learn to stand up to their mother. (Pre-existing dates with you may help.) It’s also possible, though, that your partner has some remedial work to do with his daughters before they open their hearts (and calendars) to you and their younger sisters.

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CreditChristoph Niemann

Happy to Help

My husband has two siblings. Their mother has Alzheimer’s, which is progressing quickly. (Recently, she wandered out and was unable to find her way home.) I don’t think that any of her children are offering enough support: getting her to doctors’ appointments, helping with finances or keeping her safe. Everyone lives nearby, so distance isn’t the issue. My question: How much support should I offer? I work full time. But when I’ve offered help, the siblings don’t seem to want it.

ANONYMOUS

It sounds as if your husband and his siblings may be in denial about their mother’s health. It can be frightening for adult children to acknowledge that our onetime omnipotent caretakers are now too ill or too frail to care for themselves.

But it’s even more frightening that your mother-in-law is wandering the streets helplessly. Sound the alarm! Try to persuade your husband to call a meeting of his siblings and mother to create a plan for her safety and care. (Convene it yourself if he refuses.)

There are resources, like the Alzheimer’s Association, to help your family grapple with the range of issues your mother-in-law faces. You can help, but this is not a problem you can shoulder alone. As for your siblings-in-law, it is inhumane for them to pretend that their mother’s deficits do not exist.

I Think I’ve Heard Enough

I have two neighbors who talk nonstop and overshare. One of them tells me about her travel plans in great detail, including flight times. The other describes her sick sister’s reluctance to eat and the ways she persuades her to — item by item. Help! How can I tell them that they’re sharing much more than I want to know? My husband says they need to vent, but he’s more patient than I am.

J.

Why tell these women anything? Other than their proximity, they seem to be relative strangers to you. Instructing them in your conversational preferences is nearly as odd as sharing flight times. Just smile and wave as you walk briskly to your door.

If your husband has a greater appetite for neighbors who vent, let him engage them. Most of us can divide our neighbor couples into the chatty one and the one who is less so. Be the one who’s usually in a hurry.

Do R.S.V.P.s Mean Nothing?

I hosted a bar mitzvah for my son. We took an expansive approach to the guest list. Based on responses, we paid the caterer for 138 people. But 15 didn’t show. Some of them told us in advance they couldn’t make it; others didn’t. Is it no longer rude to skip an event after saying you will attend? This is sticking with me, and I can’t find a way to tell these people I don’t approve.

ANONYMOUS

Of course the no-shows were rude! But why let the bad behavior of a few darken a joyful day in your family’s life? Nearly 90 percent of the guests showed! Now, I’m not criticizing; your feelings are pretty human.

When an angry thought about no-shows pops into your head, try to replace it with a happy memory from the day. As for the dreaded 15, you could say, “We missed you at the bar mitzvah.” But why bother? Just don’t invite to your next big do.


For help with your awkward situation, send a question to SocialQ@nytimes.com, to Philip Galanes on Facebook or @SocialQPhilip on Twitter.

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First Edition: October 17, 2019

California To Provide Financial Boost To Help Buy Health Coverage

If you are among the Californians who buy your own health insurance, a surprise may await you as the enrollment period for 2020 coverage opens this week.

Starting Jan. 1, California will become the first state to offer subsidies to middle-income people who make too much money to qualify for the federal tax credits that help consumers buy health coverage through Covered California, the state’s Affordable Care Act insurance exchange.

Many people in the middle class have struggled to afford health insurance, often shouldering the entire cost of premiums that can surpass $1,000 a month.

“The law is going to do what it is intended to do, which is to help out those people who didn’t qualify for any assistance when in reality they should have gotten something,” says Jonathan Edewards, president of Citrust Insurance Agency in Pasadena, Calif. “And those people really got hammered.”

Covered California estimates that nearly 1 million Californians could benefit from the new state money.

Also starting next year, state residents will be on the hook for a tax penalty if they are uninsured for more than three months, unless they qualify for one of several exemptions.

The penalty will mirror the federal one that was nullified — effective this year —by the 2017 federal tax reform law. In many cases, it will amount to $695 for a single adult and about $2,000 for a family of four. But for a lot of people, the financial hit could be substantially larger.

In California the deadline to enroll in coverage through Covered California or the open market is Jan. 31, but if you want the coverage to begin Jan. 1, you must sign up by Dec. 15.

Some of the $429 million worth of state subsidies available in 2020 will go to low- and moderate-income people who earn between 200% and 400% of the federal poverty level, or roughly $25,000 to $50,000 for an individual and $51,500 to $103,000 for a family of four, based on 2019 figures. This group also qualifies for federal tax credits. The average household state subsidy in this category would be $15 a month, Covered California estimates.

The lion’s share will go to those whose incomes are between 400% and 600% of the poverty level — too high for federal aid but still low enough to make health care financially challenging. That’s between about $50,000 and $75,000 a year for an individual and $103,000 to $154,500 for a family of four. The average state assistance for this group will be about $170 a month, says Peter Lee, Covered California’s executive director.

Say, for example, you are a married couple in Sacramento, both 55 years old, with an annual income of $80,000. You would not have qualified for a federal tax credit this year and would have been responsible for the entire $1,654 monthly premium for a Blue Shield of California Silver 70 HMO, the second lowest level of coverage. In 2020, you would pay $995 per month after a $688 subsidy from the state — a savings of $659 a month, despite a 1.7% increase in the premium.

You could pocket those savings, or you could bump yourselves up to a higher level of coverage with lower deductibles and copays.

For a do-it-yourself estimate of what your financial assistance might be, go to the Covered California site (www.coveredca.com) and click on “Shop and Compare.” You will be asked to enter your ZIP code, the number and ages of people in your household, and your family income.

The tool will show you a list of health plans, how much you would pay per month for each and the subsidy amount, if any, labeled “monthly savings.” Hover on that, and you will see a breakdown of state vs. federal dollars.

But before you sign up, seek free help from an insurance agent or enrollment counselor, who can guide you through the complexities of the process. Find one in your area by visiting the Covered California website and clicking on the “Find Help” tab. You can also search for local insurance agents at the National Association of Health Underwriters website (www.nahu.org) under “Membership.”

A word of caution: Be careful estimating your income. If you end up making more than you guessed, you may have to pay back some or all of the financial aid.

That has been the case for the federal tax credits since the health insurance exchanges debuted in 2014.

“That’s caused a lot of stress. I have two people this year who owe about 20 grand,” says Larry Pon, a certified public accountant in Redwood City, Calif.

You may also have to pay back some or all of your state aid if your income exceeds your estimate, but the details of how much you will owe are being finalized.

On the flip side, if you make less than expected, you can retroactively claim the credit, whether state or federal, when you file your taxes — but only if you enrolled in a health plan through Covered California.

So if you don’t seem to qualify for financial aid but think your income might drop, or you’re just not sure, strongly consider signing up with Covered California — even with no initial subsidy — instead of buying a plan through the open market.

“I am putting anybody on Covered California if there is any potential for their income to fall,” says Tom Freker, a Huntington Beach, Calif.-based insurance agent.

Maribeth Shannon and her husband, residents of Napa, Calif., plan to switch to Covered California in 2020. They are paying $1,671 out of pocket each month for a Kaiser Permanente bronze HMO that they purchased outside the exchange, and they just learned it will rise to $1,834 in 2020. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanante.)

Shannon, 63, is retired. Her husband, also 63, is self-employed, and his income fluctuates. She thinks that by working less, he can reduce it enough next year to qualify for a state subsidy. He’s been wanting to cut back anyway, “and this has really given us the motivation to speed up his retirement plan,” she says.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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‘Fear Of Falling’: How Hospitals Do Even More Harm By Keeping Patients In Bed

Dorothy Twigg was living on her own, cooking and walking without help until a dizzy spell landed her in the emergency room. She spent three days confined to a hospital bed, allowed to get up only to use a bedside commode. Twigg, who was in her 80s, was livid about being stuck in a bed with side rails and a motion sensor alarm, according to her cousin and caretaker, Melissa Rowley.

“They’re not letting me get up out of bed,” Twigg protested in phone calls, Rowley recalled.

In just a few days at the Ohio hospital, where she had no occupational or physical therapy, Twigg grew so weak that it took three months of rehab to regain the ability to walk and take care of herself, Rowley said. Twigg repeated the same pattern — three days in bed in a hospital, three months of rehab — at least five times in two years.

Falls remain the leading cause of fatal and nonfatal injuries for older Americans. Hospitals face financial penalties when they occur. Nurses and aides get blamed or reprimanded if a patient under their supervision hits the ground.

But hospitals have become so overzealous in fall prevention that they are producing an “epidemic of immobility,” experts say. To ensure that patients will never fall, hospitalized patients who could benefit from activity are told not to get up on their own — their bedbound state reinforced by bed alarms and a lack of staff to help them move.

That’s especially dangerous for older patients, often weak to begin with. After just a few days of bed rest, their muscles can deteriorate enough to bring severe long-term consequences.

“Older patients face staggering rates of disability after hospitalizations,” said Dr. Kenneth Covinsky, a geriatrician and researcher at the University of San Francisco-California. His research found that one-third of patients age 70 and older leave the hospital more disabled than when they arrived.

The first penalties took effect in 2008, when the Centers for Medicare & Medicaid Services declared that falls in hospitals should never happen. Those penalties are not severe: If a patient gets hurt in a hospital fall, CMS still pays for the patient’s care but no longer bumps up payment to a higher tier to cover treatment of fall-related conditions.

Still, Covinsky said that policy has created “a climate of fear of falling,” where nurses “feel that if somebody falls on their watch, they’ll be blamed for it.” The result, he said, is “patients are told not to move,” and they don’t get the help they need. To make matters worse, he added, when patients grow weaker, they are more likely to get hurt if they fall.

Congress introduced stiffer penalties with the Affordable Care Act, and CMS began to reduce federal payments by 1% for the quartile of hospitals with the highest rates of falls and other hospital-acquired conditions. That’s substantial because nearly a third of U.S. hospitals have negative operating margins, according to the American Hospital Association.

Nancy Foster, the AHA’s vice president of quality and patient safety policy, said these policy changes sent “a strong signal to the hospital field about things CMS expected us to be paying attention to.” Limiting patient mobility “certainly is a potential unintended consequence,” she said. “It might have happened, but it’s not what I’m hearing on the front line. They’re getting people up and moving.”

While hospitals are required to report falls, they don’t typically track how often patients get up or move. One study conducted in 2006-07 of patients 65 and older who did not have dementia or delirium and were able to walk in the two weeks before admission found they spent, on average, 83% of their hospital stay in bed.

While lying there, older patients often find themselves tracked by alarms that bleep or shriek when they try to get up or move. These alarms are designed to alert nurses so they can supervise the patient to safely walk — but research has shown that the alarms don’t prevent falls. Often stretched thin, nurses are deluged by many types of alarms and can’t always dash to the bedside before a patient hits the ground.

Dr. Cynthia J. Brown, a professor at the University of Alabama at Birmingham, has identified common reasons older patients stay in bed: They feel too much pain, fatigue or weakness. They have IV lines or catheters that make it more difficult to walk. There’s not enough staff to help them, or they feel they’re burdening nurses if they ask for help. And walking down the hallway in flimsy gowns with messy hair can be embarrassing, she added.

Yet walking even a little can pay off. Older patients who walk just 275 steps a day in the hospital show lower rates of readmission after 30 days, research has found.

Across the country, efforts are afoot to encourage hospital patients to get up and move, often inside special wings called Acute Care for Elders that aim to maintain the independence of seniors and prevent hospital-acquired disabilities.

Another initiative, called the Hospital Elder Life Program, which is designed to reduce hospital-acquired delirium, also promotes mobility and has shown an added benefit of curtailing falls. In a study of HELP sites, there were no reported falls while staff or volunteers were helping patients move or walk.

Barbara King, an associate professor at the University of Wisconsin-Madison School of Nursing, studied how nurses responded to “intense messaging” from hospitals about preventing falls after the 2008 CMS policy change. She found that pressure to have zero patient falls made some nurses fearful. After a fall happened, some nurses adjusted their behavior and wouldn’t let patients move on their own. CMS declined a request for an interview and did not directly answer a written question about whether its falls policy has limited patient mobility.

In 2015, King studied a nurse-driven effort to get more patients walking on a 26-bed hospital unit in the Midwest. The initiative, in which nurses encouraged patients to get out of bed and documented how often and how far they walked, boosted ambulation.

Hospitals still face barriers, such as the shortage of staff time, walking equipment and ways to record ambulation in electronic medical records, King said.

Getting more patients out of bed will also take a significant change in mindset, she said.

“If we think that a patient walking is a patient who will fall,” King said, “we have to shift that culture.”

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Refereeing Pete Buttigieg, Elizabeth Warren On Public Support For ‘Medicare For All’

Mayor Pete Buttigieg of South Bend, Ind., sparred with Sen. Elizabeth Warren (D-Mass.) at the most recent Democratic presidential primary debate over how to expand health insurance coverage for all Americans.

Buttigieg said he favors allowing Americans younger than 65 to enroll in Medicare if they wish. Warren, by contrast, prefers to transition all Americans from their current insurance plan to government coverage.

“Elizabeth supports ‘Medicare for All,’ which would provide all Americans with a public health care program,” her website says.

Here’s what Buttigieg said at the Oct. 15 debate in Westerville, Ohio:

“I don’t think the American people are wrong when they say that what they want is a choice. The choice of Medicare for All who want it, which is affordable for everyone, because we make sure that the subsidies are in place, allows you to get that health care. It’s just better than Medicare for All whether you want it or not. And I don’t understand why you believe the only way to deliver affordable coverage to everybody is to obliterate private plans.”

Is Buttigieg correct to say that Americans prefer giving people under 65 an option to join Medicare as opposed to requiring them to give up their current coverage?

As we seek to answer this question, we’ll begin by noting that terminology and question wording matters a lot when pollsters ask Americans for their preferences.

Looking at the recent polls on health policy reveals a wide variation in how questions are worded, making many of them not useful for refereeing the Buttigieg-Warren exchange.

However, we did find two polls from 2019 that are on point — and both of them support Buttigieg’s position.

An NPR/PBS News Hour/Marist poll conducted in mid July asked, “Do you think Medicare for all, that is a national health insurance program for all Americans that replaces private health insurance, is a good idea or a bad idea?” This is essentially the Warren approach.

On that question, 41% of respondents thought that was a good idea, but a larger percentage — 54% — said it was a bad idea.

A second question by NPR/PBS/Marist asked respondents about an approach more in line with Buttigieg’s idea.

The survey asked, “Do you think Medicare for all that want it, that is, allow all Americans to choose between a national health insurance program or their own private health insurance, is a good idea or a bad idea?”

That proposal earned a strong thumbs-up from respondents: 70% said it was a good idea, with only 25% saying it was a bad idea.

A second poll — conducted by the Kaiser Family Foundation in January 2019 — found stronger support for the Buttigieg approach than for the Warren approach. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

The survey asked, “Do you favor or oppose having a national health plan, sometimes called Medicare-for-all, in which all Americans would get their insurance from a single government plan?” — essentially the Warren approach.

For this question, a majority did favor it — 56% support compared to 42% opposition.

But support was even stronger for the Buttigieg approach. The survey asked, “Do you favor or oppose creating a national government administered health plan similar to Medicare that would be open to anyone, but would allow people to keep the coverage they have if they prefer?”

This drew support from 74% of respondents and opposition from only 24%.

A third option with a slightly different wording fared even better in KFF’s polling. “Do you favor or oppose allowing people between the ages of 50 and 64 to buy insurance through the Medicare program?”

This won the support of 77% of respondents, compared to only 18% opposition. Support was strong across all parties: It won 85% support from Democrats, 75% support from Independents, and 69% from Republicans.

The foundation’s most recent polling, released the same day as the debate, shows a steady rise in support for the Buttigieg approach — from 65% in July to 73% in October — and a steady decline for Warren’s approach — from 56% in January to 51% in October.

Our Ruling

Buttigieg said that Americans “say that what they want is a choice” to join a single-payer system like Medicare rather than ending private insurance.

Polling on this question shows higher levels of support for an opt-in approach to expanding Medicare than for a required switch away from private insurance. We rate the statement True.

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Insurance Medicare

Surprise Settlement In Sutter Health Antitrust Case

SAN FRANCISCO – Sutter Health has reached a preliminary settlement agreement in a closely watched antitrust case brought by self-funded employers, and later joined by the California Attorney General’s Office. The agreement was announced in San Francisco Superior Court Wednesday morning, just before opening arguments were expected to begin.

Details have not been made public, and the parties declined to talk to reporters.  Superior Court Judge Anne-Christine Massullo told the jury that details likely will be made public during approval hearings in February or March.

There were audible cheers from the jury following the announcement that the trial, which was expected to last for three months, would not continue.

Sutter stood accused of violating California’s antitrust laws by using its market power to illegally drive up prices. Health care costs in Northern California, where Sutter is dominant, are 20% to 30% higher than in Southern California, even after adjusting for cost of living, according to a 2018 study from the Nicholas C. Petris Center at the University of California-Berkeley cited in the complaint.

The case was a massive undertaking, representing years of work and millions of pages of documents, California Attorney General Xavier Becerra said before the trial. Sutter was expected to face damages of up to $2.7 billion. Sutter Health consistently denied the allegations and argued that it used its market power to improve care for patients and expand access to people in rural areas. The nonprofit chain has 24 hospitals, 34 surgery centers and 5,500 physicians across Northern California, and had $13 billion in operating revenue in 2018.

The case was expected to have nationwide implications on how hospital systems negotiate prices with insurers. It is not yet clear what effect, if any, a settlement agreement would have on Sutter’s tactics or those of other large systems.

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Psoriasis Tied to Increased Cancer Risk

Having psoriasis is associated with an increased risk of cancer, a new review of studies concludes.

Researchers, writing in JAMA Dermatology, combined data from 58 studies and found that, over all, compared with people without the condition, psoriasis of any degree of severity was associated with an 18 percent increased risk for cancer, and severe psoriasis with a 22 percent increase. Cancer mortality was elevated in all cases of severe psoriasis.

For some specific types of cancer, the risk was even higher. For example, they found that severe psoriasis was associated with more than 11 times the risk for squamous cell carcinoma (a skin cancer), about double the risk for esophageal and liver cancer, and a 45 percent increased risk for pancreatic cancer.

Any degree of psoriasis, severe or not, was significantly associated with colorectal cancer, non-Hodgkin’s lymphoma, and cancers of the kidney and pancreas, among others.

The reason for the connection is unclear, but there is a known link between chronic inflammation and cancer, and this may help explain the association.

Alex M. Trafford of the University of Manchester, the lead author, said people with psoriasis tend to smoke more, weigh more and drink more alcohol, factors not accounted for in all of the studies.

“Carrying on a healthy lifestyle,” he said, “could potentially make a big difference in this risk.”

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