Financial Mistakes and Exploitation in Dementia: Lauren Nicholas, Duke Han, Jason Karlawish

Eric 00:14

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:19

This is Alex Smith.

Eric 00:20

And Alex, we’re going to be talking about financial mistakes and exploitation of dementia. Who do we have with us to talk about this?

Alex 00:27

We are delighted to welcome Lauren Nicholas, who is a health economist in the Division of Geriatrics at the University of Colorado Anschutz Medical Campus in Denver. Lauren, welcome to the GeriPal Podcast.

Lauren 00:41

Thank you. Happy to be here.

Alex 00:43

And we’re delighted to welcome my friend Duke Han, who is a clinical neuropsychologist and professor of psychology in the Dornsife College at the University of Southern California. I know Duke extremely well. We have played sing-alongs at the annual Beeson Aging Researcher Meeting for like 15 years or so. Duke, welcome to the GeriPal Podcast.

Duke 01:06

It’s great to be here, Alex. I’m a big fan of your show. So thanks for having me.

Alex 01:11

And we’re delighted to welcome back Jason Karlawish, who’s been on several times to talk about his book about dementia and other things. He’s a geriatrician and medical ethicist. He co-directs the Penn Memory Center at the University of Pennsylvania, and he’s executive producer of the Age of Aging podcast. Jason, welcome back to JerryPal.

Jason 01:32

Thanks, Alex. Great to be back with you guys.

Eric 01:34

So we’ve got a lot to talk about in financial capacity, mistakes, and exploitation in dementia. But before we do, we always start off with a song request. Who has a song request for Alex?

Alex 01:46

Duke not only has the song request, he’s gonna play the song.

Jason 01:50

Wait, what?

Alex 01:51

This is great. Thank you, Duke.

Eric 01:54

What, Alex, this is like the second time or third time, I guess?

Alex 01:57

Something like that.

Eric 01:58

Yeah.

Alex 01:59

Yeah. We used to do it more often when we had more in-person stuff.

Eric 02:02

Duke, what song are you going to play?

Duke 02:04

I’m going to play All the Wrong Reasons by Tom Petty.

Eric 02:10

Why did you pick this song?

Duke 02:12

So, I think it’s the all the wrong reasons part. Honestly, I think that that always called to my mind older adults becoming entrapped in scam and fraud and I think it’s just a really unfortunate situation, and yeah, and I think there’s other references to socioeconomic considerations throughout the song. So yeah, it always reminded me of financial decision making.

Eric 02:34

Yeah, let’s hear it.

Duke 02:35

All right.

Duke 02:49

(singing)

Eric 03:34

That was lovely, Duke.

Lauren 03:37

Love it.

Duke 03:38

Oh, thanks.

Alex 03:39

Thank you, Duke. That was terrific.

Eric 03:42

And for those who are watching this on YouTube, you can see all of the music posters behind Duke. You’ve been playing for a long time, Duke?

Duke 03:51

Yeah, for a little while. Big music fan, just like Alex. So yeah.

Eric 03:57

Well, let’s dive into this topic.

Lauren 03:59

Yeah. Thanks.

Eric 04:01

Let’s dive into this topic at hand. Financial capacity, exploitation, mistakes in older adults and dementia. Lauren, I’m going to turn to you first to kind of kick us off on this topic because you’ve done some really interesting previous research looking at when does both wealth start declining and also people’s ability to kind of make these decisions. What have you learned in your past research?

Lauren 04:28

Well, I guess I have to start by noting that our research was kind of an attempt to put big data numbers on work that lots of other people in this group, including Eric and Jason, were, you know, really publicizing in both guidance for physicians and, you know, I think some of like Jason’s patients who were willing to talk to the New York Times.

And so that was, that was what first got us interested in this was kind of these stories of kind of catastrophic financial losses being the trigger that led to family members discovering a loved one had dementia. And so we got kind of interested in both how, how common is this? How, how much money are people losing? Can we see it in large-scale data in ways that might help us eventually catch things early and prevent some of these losses? And so the, the good news and the bad news is we, we can see it in lots of different financial datasets.

We see 6 to 8 years before either a clinical diagnosis when we’re using Medicare claims data, or even developing cognition that would be consistent with a dementia diagnosis when we have HRS survey data where you don’t have to rely on the patient actually seeing a doctor. So, there’s this very long period of time where we’re losing financial skills, but still presenting as relatively cognitively normal.

Lauren 06:11

And we see this in like missed bill payments. We see, increase in foreclosure because you’re not paying your mortgage. We see losses on average of $100,000 across, you know, all, all sources of wealth just in those 6 years before diagnosis compared to people who don’t develop dementia. So like really large striking financial differences.

Eric 06:42

Can I ask, is it because a doctor has never made a diagnosis of dementia, or is this even before we would think that they have dementia based on these HRS questions? They’re losing vast amounts of money. They’re not paying their bills. Their credit scores are dropping. Can you separate those 2?

Lauren 07:04

Yeah. So I think what’s, what’s sort of nice about HRS is everyone gets asked the cognitive screening questions regardless of whether there’s been a clinical diagnosis. And so we are just able to say, you know, would your cognition be diagnosable as probable dementia? Because like in the Medicare claims, we worried that, oh, you know, people might be getting delayed diagnoses or not getting diagnosed at all. Claims data, you know, have had numerous problems, but it was the best. source of information we could get.

And so it’s, it’s not just that you’re not getting diagnosed, it’s that even if you were going to your doctor like every year and asking for the cognitive screeners, you would show up as relatively cognitively normal while you’re making these financial mistakes, which is the part that I find especially horrifying.

Jason 07:58

Well, I think what Laura’s work shows and it triangulates with other work, by other teams using different kinds of data, financial data, for example, is these problems are antecedent by several years before a dementia diagnosis would maybe routinely be made. So it upends one idea. Yeah. It upends one fiction, which is people with MCI are fine.

Alex 08:24

Yeah.

Jason 08:24

You know, because they’re not demented, which is part of the MCI definition. But instead, I think it hammers home what is out there in the literature and studies of MCI, Which is they do have impairments in, um, decisional abilities. And, and so MCI is a clinical diagnosis, meaning it can, people with MCI can have problems. And no surprise, what’s top line problem is financial decision-making because it is very cognitively demanding, which I think Duke could probably explain better than I can because Duke’s actually a psychologist. Uh, yeah. So why is financial decision-making so hard?

Alex 08:58

Yeah.

Duke 08:59

So I have a lot of thoughts on this. So I think when we’re talking about finances, it really draws upon lots of different systems in the brain, right? Like you’re drawing upon your calculation ability, but also your value system. You’re assessing value with respect to others in your social circle or your family circle. So there’s multiple different processes going on in the brain. And so I think this might be the reason why it might be one of the first functions that sort of shows that it’s falling off in the context of, of early dementia.

So, and I, I think Lauren’s work in this area has been really instrumental because I, you know, she has one of these seminal papers actually that really demonstrates this in a very compelling way in the HRS data. And a lot of the work, I think we have Jason to thank. He’s one of the first people in the field to really do research in this area actually. And so a lot of this is built on Jason’s work. So I just wanted to acknowledge that. But yeah, we’ve been interested in cognition, how it relates to decision-making. Jason, you mentioned MCI.

So we do find that people with MCI, at least some do, show poor financial decision-making, but we even find it even earlier than when people get diagnosed with MCI. So it’s, this might be one of the earliest functional markers of Alzheimer’s disease, and it’s something that we’re just trying to understand better.

Jason 10:17

And related causes of dementia. The, you know, as you guys know, I’m Buck Parker hot.

Eric 10:22

Yeah.

Jason 10:22

So let’s, let’s, let’s get ADRD on the table here.

Eric 10:26

So I got a question. Do we have to redefine what MCI is?

Jason 10:31

Because isn’t by definition, you’re mostly intact from your, you know, I think MCI is a label that is, that has a historical understanding. Namely, that was back when to have Alzheimer’s, you had to have dementia. The paper was published in 1999 out of the Mayo Group. They were in this nomenclature world where Alzheimer’s is dementia, dementia is Alzheimer’s.

The problem is the very label though has this weird description. Well, it’s, it’s, it’s just mild cognitive impairment. Well, that’s like actually saying back to someone what they already have told you, which is I have cognitive impairment. It’s mild.

Lauren 11:04

Yeah.

Jason 11:05

And to me, it’s an early stage of cognitive impairment where, as Duke pointed out, there’s problems with social cognition, executive function, working memory, subtle. But once you give them the demands of a financial task, particularly a novel financial task, you know, that’s where mistakes happen.

Eric 11:22

And just to clarify, so with MCI, I’ve always been taught it’s not impairing your independent functional daily activities.

Jason 11:31

I think that that is just not correct. You know, the earliest person to discover that was Dan Marzen and Dan Marzen developed a financial capacity instrument. And it goes through like, how do you do a checkbook? How to pay a bill? It’s a very meticulous measure. And he showed people with MCI had impairment on their scores.

Eric 11:48

One of the first articles that I wrote, I got into JAMA on the importance of financial capacity, even diagnosing dementia. It was with Dan and I’m still from that, from writing that article, I’m like, wait, but MCI says You know, if you, if you have MCI, you don’t have functional impairments, but now we’re showing you have functional impairments. So how should I think about it? And I’m still confused. And it sounds like maybe it’s just that where we are with nomenclature right now.

Jason 12:13

MCI is non-dementia.

Lauren 12:16

Yeah.

Jason 12:16

Dementia means disability. It means you are making mistakes and need help. And you know, where that begins is a blurry area.

Eric 12:24

But it sounds like if you’re losing $100,000 on You’re making mistakes and need help.

Alex 12:30

And this is 6 years before diagnosis with Alzheimer’s.

Jason 12:32

All the more reason to get diagnosed.

Lauren 12:34

But I think we don’t, sorry, we don’t have great ways yet, although we’re hoping to change that, of sort of transmitting that information to physicians. So in many cases, I think people are sort of trying to make diagnoses without one of the big clues. And if, if we’re lucky, somebody notices that these losses are happening. But often you don’t catch the earlier signs. And it’s, it’s also tricky because there are so many different financial management tasks that we do in day-to-day life.

Jason 13:06

Yeah.

Lauren 13:07

And it sort of presents differently in different people. So, you know, if we could just say, oh, once you miss that bill payment, you probably are developing cognitive impairment, but it might be, oh, you’re, you’re just making excessive purchases, but you’re paying for them. But you, yeah. clearly don’t want them, or you got yourself on one of those political campaigns.

Jason 13:29

All the banks, all the bankers I talked to, the senior level people in the various banks, big banks will tell you our call centers age after 75, it just takes off. You know, the other customers, they’re rarely calling if they call, whatever, but it’s, it’s the over 75-year-olds who are calling because something’s not making sense, except I have to reset my password yet again, or I just got this phone call and they said that if I transferred money to this account that you … they’re clearly being scammed. I mean, 75 plus, which is of course the age of risk.

So yeah. And I mean, what Laura’s work is so tragic is a lot of this is like the early work you did, Laura, which showed that it was credit data. So basically credit card companies who are making money off of your delayed payments because they charge you interest plus penalty.

Lauren 14:15

Yeah.

Jason 14:16

And, and so the American credit industry is making money off of ADRD.

Alex 14:20

That’s terrible.

Jason 14:22

Yeah.

Eric 14:23

Duke, I got a question for you.

Jason 14:24

Yeah.

Eric 14:25

Why is this happening so early on? Like, what’s actually going on in the brain? Do we know anything? Yeah.

Duke 14:32

So a lot of our work that’s based here out of USC is trying to understand why certain older adults make financial, just poor financial decisions in the presence or in the absence of any sort of cognitive impairment or overt cognitive impairment. And one of the ways that we’ve been trying to understand that is actually neuroimaging. So we know that we can scan brains and actually see changes in brains that happen years before cognitive change, actually.

So we thought, well, if we can do that for cognitive change, we can see changes in the brain ahead of that, you know, why can’t we do that for financial decision-making? And so we’ve been actually scanning older adults who don’t show any real signs of cognitive impairment yet. And what we’re finding is that there are these subtle brain changes that are happening that correlate with poor financial decision-making. And a lot of the brain changes are actually consistent with early dementia, actually. And so this is how it all ties to dementia. We think that actually a lot of this poor financial decision-making that happens in the context of seemingly intact cognition might be early brain changes because of encroaching Alzheimer’s disease. Now, it’s not going to happen in every situation.

There’s all these really specific cases that, and details that we need to pay attention to, right? Like, it’s not that older adults make poor financial decisions because of poor cognition or declining brain imaging. It could be other social factors, other factors. We’re actually trying to study that as well. But at least in a good part of our work, we are showing that early brain changes consistent with early Alzheimer’s disease seem to be correlating with poor financial decision-making in older age.

Jason 16:09

What imaging are we talking about here?

Eric 16:10

What are you doing?

Duke 16:12

So we’re actually doing lots of different kinds of imaging right now. We have the benefit of this really high-field 7T MRI magnet, which is basically a fancy way of saying we can really look at details in the brain. So we’re looking at structural brain changes. We’re looking at connectivity between brain regions.

Jason 16:28

So it’s 7 Tesla MRI.

Duke 16:30

Right now we’re using 7 Tesla. A lot of our early work was using a 3 Tesla, which is very common in the communities.

Alex 16:35

Yeah.

Duke 16:35

We use 3 tests.

Alex 16:37

Yeah.

Jason 16:38

Yeah.

Eric 16:38

Do you, do you connect with biomarkers at all too?

Duke 16:41

Actually, that is our very purposeful— sure. Actually, so, so I actually just wrote a grant that I’m hoping gets reviewed well in October to introduce blood-based biomarkers. We have some pilot data that does suggest things like financial literacy seems to correlate with p-Tau 217 actually when adjusting for demographics. So It does seem to fit, at least this, some of the data that we’re collecting, that a lot of the early financial decision-making brain changes could be because of encroaching neuropathology from Alzheimer’s.

Alex 17:17

So if we want to argue that it’s important to detect early cognitive change for whatever reason, to prepare people to intervene at an early stage for some reason, we can talk about that separately. But if we agree on that, I’m hearing that there are 3 ways that we could do that so far. One is we could give them a financial literacy question, some novel question that they haven’t had before, and see how they do.

The second is we could scan their brains and see if there are changes that are indicative and associated with early cognitive changes and financial literacy. And a third is potentially the blood-based biomarkers. And I mean, which should we do and why?

Duke 18:05

I don’t know.

Jason 18:06

Can I put a fourth one?

Alex 18:08

Say again, Jason.

Eric 18:08

Yeah. Fourth one, Jason.

Alex 18:10

A fourth one. Yeah.

Jason 18:11

So we could go to the data from HRS, which said, ask the simple question, are you having trouble managing your money? And if someone affirms that, they are telling you Essentially, never mind diagnostic labels, that there’s trouble going on in my connectivity networks that Dr. Ha knows all about. And, you know, if, if, if you follow me long enough, Lauren’s going to pick it up. So it’s a very simple question and it was actually an HRS and it correlated well with only about 3% of people who have normal cognition.

HRS said they were having trouble. The number leapt up in the MCI group and it leapt up even higher in the dementia group. So I think that’s a very simple question that a clinician can ask.

Alex 18:53

I love it. Co-director of the Penn Memory Center, not arguing for a blood-based biomarker or brain imaging, arguing for this simple question.

Jason 19:02

Yeah, but simple question. But, but yeah, I mean, isn’t the vision of the future that a combination of probably structural neuroimaging to really show network disruptions together with a biomarker to give you the the pathology at work would be that combination together with, of course, the patient’s subjective experience. And then Lauren can tell us what financial transactions the United States should be tracking and telling our patients, telling the clinicians about. But that’s a different story. Yeah.

Lauren 19:31

And one of the things we are working on is trying to figure out whether we can get sort of predictive enough in some of these financial datasets that that would be either useful on its own or useful to be like transmitted to your doctor before your visit or your bank. We could say, you know, this person has an elevated probability of developing dementia.

So if they ask you to do something sketchy, you need to put more guardrails in place than your traditional process. But I think all, all of those things will require both policy changes and collaboration across sectors that don’t usually talk to each other.

Eric 20:12

And Lauren, I’m trying to remember one of your studies. So I think Jason alluded to it, it is that you found that most older adults are managing their finances, right?

Alex 20:23

Alone.

Lauren 20:23

Yeah. Like 70% of people with dementia are still managing their own money. And many of them, as Jason said, report that they have difficulty doing that.

Eric 20:33

But once you have dementia, it looked like looking at those graphs, we’ll have links to it in the show notes. Like the diagnosis of dementia actually significantly increased the chance that you’re having difficulty managing that.

Lauren 20:48

Oh yeah. It’s like a very, very nice.

Alex 20:51

Yeah.

Eric 20:52

Which highlights potentially Jason’s point is actually asking the question, are you having difficulty even for people who have dementia? Still probably an important question to ask.

Jason 21:01

Yeah. And there’s another set of questions that came out of the, came out of the Rush group, uh, which were 4 questions that kind of got at your vulnerability to scams. And they’re really like, like, I have a hard time hanging up the phone. if something sounds too good, it probably is. You know, people saying, well, no, you know, in other words, their answers were sort of suggestive of, I’m kind of vulnerable to scams. And scores on that measure of vulnerability to scams, which were very simple questions that people in a survey had answered.

This is kind of tragic. They predicted incident MCI and dementia. In other words, you ask me these questions now and then come back 4 years later in the Rush study, which is a meticulous follow-up. I mean, they follow people up And then when they die, they get their brains. It predicted incident dementia. So there are these questions that could be built into, along with, you know, the 5,000 questions unfortunately we ask people about falls and et cetera.

Eric 21:50

So let me ask you that, Jason. How important is it that doctors, nurse practitioners, other healthcare providers get involved in somebody’s financial decision-making? Like, or should we just stick to Normal healthcare topics.

Jason 22:07

Well, I think in dementia, nothing’s normal. We know that, fellow dementia experts. And given how dementia ramifies into life, and for one of the first IADLs to go is managing finances, otherwise known as financial capacity, just to link those concepts to geriatric language, function, IADL, financial capacity.

Eric 22:27

Yeah.

Jason 22:27

I mean, you can make an argument we have a responsibility because, you know, Dementia’s an expensive disease. You know, once disability kicks in, families pay and pay and pay. And what could be more tragic than like what one of my patients turned to her daughter and said, you know, I think I’ve been scammed. And what happened was she had gotten sucked into a lottery scam and basically garnished her 401 plan. You know, the family stepped in and covered for her ultimately. But, you know, for many families, those kinds of events are tragic, meaning loss of income plus loss of dignity and a host of other harms.

Alex 22:58

Yeah.

Jason 22:59

Yeah, I think we have to wade into that space. MDs, not always necessarily. I mean, there are plenty of paraprofessionals that should weigh in. I think the bigger question, which Lauren alluded to, is where’s our friends from Morgan Stanley?

Eric 23:10

Sounds like they’re making money on this.

Lauren 23:13

Well, they are making money.

Jason 23:15

I would say that I, when I read Lauren’s work around the credit industry, you know, who get fees on late payments, et cetera, I thought, my God, you know, it’s one thing to say, look, I couldn’t make my bills because, you know, whatever. but I’m not making my bills because my brain’s falling apart. You’re seeing it happen in live, real stream time. That kind of starts to hurt.

Lauren 23:37

Yeah.

Eric 23:37

Tell me about that, Laura.

Lauren 23:39

Yeah. So as we kind of looked at in the credit data, there’s a very useful measure is whether you’re paying your bills on time. And we look at bills that are more than 30 days past due, which basically means that you’ve Fail to pay it twice. And once you, even after you’re like one day late, banks charge you a late fee, which is usually about $35 each time, and they change your interest rate to a penalty interest rate. So they can be charging you like 30, 40% interest on your unpaid balance. And so this, you know, easily adds up to like $1,000. In that just the pre-dementia period yet again.

Eric 24:27

So, is there any incentive for the banks to, I mean, it sounds like there are incentives for the banks to put their head in the sand on this. Is there any incentive for them not to, to actually, you know, get involved?

Lauren 24:40

I think some of them do see it as sort of a marketing plus if you can save your clients money and prevent some of these scams that Does seem to engender loyalty.

Jason 24:52

It’s a business model. It’s a business question. Look, if I had a firm where fundamentally a big chunk of my profit pie is late payments and related fees, because that’s just what we’ve been, that’s what we figured out like that, you know, and, you know, consumer voluntary non-fit injury, you know, you, you, you manage your money and we’ll help you out with this card. You know, this would be a challenge, but on the other hand, if your business model is something else like, I get all this credit data because I then sell it to every marketer in the world and et cetera.

Then actually, as Laura points out, the business model here is, yeah, let’s set up a notification system to let people know, you know, you’re, you know, that’s even, would you like to have your trusted contact in our system so that if there are troubles, we’ll contact them or we’ll et cetera. And there are some, for example, banks. Now I’m moving into the bank space. that have proactively set up systems that when you flag, like my patient who called up and wanted money transferred to pay the tax on the lottery, total scam.

And if she had used this other bank that actually exists in the United Kingdom, they would’ve flagged that and called her back automatically and said, you know, we want to alert you that there are scams that involve saying you’ve won a lottery and you need to pay your taxes. If you think this may have happened to you, you can cancel your transaction and they can hold the transaction for a period of time until it’s done. And these kinds of interventions have been shown to reduce the incidence of these kinds of scams and whatnot.

So you just have to see it as your business model, that identifying and intervening. The problem is, of course, liability, that if not problem, but the challenge then is liability. So how far is this my responsibility? Like, am I now Jason’s personal financial manager and coach?

Eric 26:37

Yeah.

Jason 26:37

what point do I say, look, you know, I did what I said I was going to do and that’s all. Don’t come after me. And I think a lot of these institutions struggle with these issues of what’s my business model, what’s my liability, what’s my responsibility?

Eric 26:49

So Duke, I got a question for you because Jason also mentioned social connection.

Duke 26:55

Yeah.

Eric 26:56

What do we know about risk for, you know, financial exploitation, mistakes, And the social connectedness of older adults? Yeah.

Duke 27:07

So a lot of this work comes from the elder abuse world actually, of which I know Jason and others are well aware of, that there’s this general tenet that as older adults are more socially isolated, they’re more vulnerable to elder abuse of all different forms actually. So that applies to financial abuse as well. Our own work has been trying to look at this a little bit more closely, and some of our work has suggested, for example, It’s really about how deep of a connection you have with others. It’s not really about how many connections you have.

You can have connections to 100,000 people, but if you don’t have deep connections, then it’s really that’s going to be the most important thing that’s going to be protective for financial exploitation or financial vulnerability. So the social dynamics are really important. We’ve also had other work that we’ve done during COVID when we couldn’t see anyone face-to-face anymore. We checked in with older adults every 2 weeks for 6 months just to kind of track their financial vulnerability related to various different factors.

And one of the factors that seemed to be most predictive of financial vulnerability was the quality of their social relationship. So as the quality of the social relationships, as the ratings went up, their financial vulnerability ratings went down, and then vice versa, as their quality of social relationships went down, the increase in financial vulnerability was seen actually. And so it, it really does seem to be the case that social dynamics Social factors are really important to consider when you’re considering financial vulnerability of older adults.

Jason 28:39

And by the way, this reiterates the Lancet 14 risk factors for dementia. Loneliness and isolation are one of the risk factors that have been put on as a risk factor for developing dementia. So all the more reason to focus on and address that as a social problem.

Alex 28:53

And I’ll say personal anecdote, and I don’t remember who suggested this, But I ask my mom if she’s going to make any major financial decision, she should run it by me first. And I think that’s just sort of a practical thing we could say to our patients as well. And I didn’t come up with that. I don’t remember who did, but I think it’s like, it’s exactly what Jason was talking about. You should have a trusted person who you can, before you invest in X or spend money on Y or pay the tax on the lottery, there should be somebody that you check in.

Eric 29:27

Can I ask a quick question based on that? Because I wonder, have we looked into, have you looked into all like partners, spouses, and what happens when one spouse dies? Because I mean, for me, like I’d be screwed because my wife handles all the finances.

Alex 29:41

She’s the CFO.

Eric 29:43

But like we do run things by each other. So there’s this, there’s almost checks and balances and what happens for older adults when their partner Yes.

Lauren 29:53

So having, we can’t totally tell if it’s a spouse in a lot of our datasets, but having somebody live in your house who is about your same age and probably is a spouse, um, is a little bit protective, but not as protective as we were hoping.

Jason 30:11

Yeah.

Lauren 30:11

I think it’s part of this, like many households do use that CEO model where one person Yeah. Does most of the financial decision-making. And if that’s the one who develops dementia, we’re still going to see it. And we have done some recent work where we look at widows. And so widowhood for a long time has also been associated with negative financial outcomes for a lot of reasons, including like the cost of the first partner’s care.

And so what we see in these dementia households is the financial problems are starting before death and then it’s bad for a couple years, but clears up more quickly. Whereas with a non-dementia household, we just sort of push that loss out a little bit. And so you’re doing better when the other spouse is alive and then you experience a drop-off. So it’s, it’s more of a question of when it happens than do these losses happen, unfortunately.

Alex 31:14

Duke, anything you’d add to that?

Duke 31:17

Yeah, no, I think Lauren captured it. This is something that we have been picking up on in our research and we’re trying to do more research about it. These very significant life changes, right? Like loss of a spouse. I think diagnosis of a major medical condition. It seems to be that a lot of scam and fraud happens around this, unfortunately.

And I had a family member who went through cancer recently and it was shocking to me that the scams that came to this person as soon as this person was diagnosed. It was almost like I couldn’t figure out how people figured it out actually, or knew about it, but it was almost like scammers actually know this and they target people who are at their most vulnerable. So it’s a, it’s a sad situation for sure.

Alex 31:58

I was just speaking of spouses. Bear with me, dear listeners. I just listened to the Ezra Klein podcast where he interviewed his wife Annie Lowrey about the time tax, and she has a book coming out about this. And this is about, you know, the time that people spend filling out forms, doing paperwork in order to receive benefits like entitlements, et cetera, you know, food stamps, SNAP, Medicaid, et cetera. And we have this enormous bill that was passed, the One Beautiful Bill, and the delayed Medicaid changes, which will come into effect shortly.

Which will present enormous amount of burden, additional burden on older adults. The work requirements are people under 65, and we take care of a lot of older adults who are, you know, 50 to 65 who have disability and cognitive impairment, et cetera. And it also delayed some of the planned methods to make Medicaid simpler administratively for older adults who are over age 65. So I really worry. And Lauren, there was this key piece, I think, in your research that the poor, low-income people were at greater risk. Anything you’d like to say about that? Is that right?

Lauren 33:16

Yeah. So, and I think that’s at least some of that came from a suggestion from Duke as one of our reviewers. And we were able to separate into higher and lower education groups, which is our sort of best marker for socioeconomic status later in life. And among those with less education, the problems started many more years prior to diagnosis, and they were much more common and sort of affected a larger share of that population compared to the relatively high education groups.

And so we, we don’t know what the exact pathway is. Is it differences in financial literacy? Is it differences in, you know, you’re just going to miss more payments if you have less money available to you? Is it delayed diagnosis because of access to care? Probably some combination of a lot of bad things happening. And I think the other thing that’s sort of related to this and important is sort of what you’re saying, how, how complicated we make so many choices around aging.

So like we used to do pensions that just sent you a check every month, and now we want you to have a 401 that you manage yourself and, you know, liquidate some minimum distribution every year and do the right thing. With those funds, there’s work that’s shown that people make worse choices of Part D plans. So those are relatively standardized, right? If you know your drugs, you should be able to pick the plan that yields the lowest out-of-pocket spending. And people who go on to develop dementia also make worse choices there. So I think there’s, there’s just so many ways.

Eric 35:13

Yeah.

Lauren 35:13

Where we’re not set up for the sort of cognitive reality Of older Americans.

Jason 35:20

I think it’s time now to introduce the conceptual model that needs— that American medicine and finance need to embrace, which is the model of wealth care, which is my clever play on 2 words, wealth and health, namely wealth care, W-H-E-A-L-T-H care. In other words, once one begins to see the intimate connections between your health and your wealth, Here we’ve been dealing a lot with sort of diagnostic matters, but obviously matters related to care have come up in those.

You need your wealth in order to have your health care of. I mean, I think you see this case for the need to practice wealth care in America and it’s going to require a shift in laws, cultures, customs, and business practices in the medicine field, healthcare field, and in the wealth care field, banking, finance, Social Security. Just provides checks to millions of Americans.

Eric 36:18

Yeah. I mean, I think it’s fascinating because both are kind of extractive fields that are extracting wealth from the person, which scares me a little bit about banks getting too involved in my healthcare and also healthcare getting too involved in my finances.

Jason 36:35

But I think we have to start thinking about how they can. Yeah.

Eric 36:38

In a responsible Yeah.

Jason 36:41

I mean, the Trendall study that came out of the UK was a large bank, and what they had was like 16,000 people who had a financial power of attorney. In other words, meaning this person has lost the capacity to manage finances. Here’s the power of attorney. And they said, all right, that group compared to the 50,000 people who didn’t have one, let’s go back and look at those 2 groups and look at the pattern of banking behaviors. that they exhibited over 10 years prior to that incident event.

And what they showed was a host of different financial differences in financial behaviors. In other words, over time, the people who ultimately had a financial power of attorney in place were more likely to not be spending money on things that involve travel, et cetera. And they were more spending on things that require staying in the home. So almost a marker of what’s been known for a long time, which is shrinkage in life space.

Alex 37:35

Yeah. Mm-hmm.

Jason 37:36

But even more interesting was upticks in password resets, upticks in frequent calls to have further clarifying at the bank kind of calls and things like that. So you could almost put together like a banking phenotype of someone who’s vulnerable and then think about ways that that phenotype could be made available to someone who cares about that person as part of the Gee, you know, yeah, you were p-Tau 217 positive, et cetera, but now we’re beginning to see these problems emerge. All the more reason that you need to set up this monitoring system. It’s not an impossible way. It’s just going to require industries to start talking to each other.

Eric 38:15

With the right guardrails, because they could also sell that to advertisers who can then make a lot of money based on vulnerable older adults. So I do want to get in the last couple of minutes, like thinking about Okay. I am a provider and I’d love to hear from each one of you, like your thoughts from an economist, a psychologist, a physician standpoint. Jason, what was the number one question you said? It was, are you having difficulty managing your finances?

Jason 38:41

Managing your finances, your money.

Eric 38:43

Yes. What do I do? Like, I am not, I told you my wife manages my finances. Like, how am I supposed to, what do I do in that setting if I get a positive answer? What’s my role?

Duke 38:57

So I’m a neuropsychologist and I do cognitive testing for dementia all the time. So I, and I do ask that question, actually I’ve started doing that recently. And if I do get a positive response, for me, it does make me concerned about dementia. So I will actually then refer for additional testing for early dementia in that case. And so I think from my perspective, that’s, that’s been the norm. And in some ways I advise that actually.

Lauren 39:20

Okay.

Eric 39:20

So it should be a flag that you should be screening for dementia. Lauren, what else should it be? Cognitive impairment. Cognitive impairment.

Jason 39:29

Right, Duke, right?

Eric 39:30

But I also heard that happens well before we can even diagnose.

Duke 39:35

Cognitive assessment in general.

Lauren 39:37

All right.

Alex 39:37

Cognitive assessment.

Jason 39:38

Yeah.

Eric 39:38

What else should it do?

Lauren 39:40

I think I would like to have greater integration of, you know, access to social workers, lawyers, people who can actually help you put these things in place. Before we get to the point where we’re worrying about dementia and having, you know, your, your doctor can, can refer you to some place that can actually do what you need to do. Because when conditional on living to 65, something like 40 to 60% of older adults are going to develop dementia. So it’s like, if we’re lucky to live long enough, we are going to have these. financial problems and we should be kind of structuring our lives when we’re still able to do it in such a way that the guardrails are already in place. Right.

Eric 40:28

And are those types of things you’re thinking about, like setting up a durable power of attorney for finances with somebody that you trust?

Jason 40:34

Well, maybe I, let me, I mean, remember if I give you my durable power of attorney for finances, you can go into my bank and clean out my cash because you have a power of attorney.

Eric 40:43

It depends on what the Bureau of the Public Attorney says. Like if it says you need 2 physicians to say this person lost capacity.

Jason 40:48

Sure. I mean, the conditions need to be there, but a plain vanilla DPA is that. So is it springing, et cetera? Yeah, I agree with you. I’m not saying no to DPAs, but I do think the starting question to someone who says, you know, I’m really struggling, I’m having trouble managing my money. Well, you know, tell me more about that because Duke’s point is diagnostic. It can Okay. And then Lauren’s point is it’s getting to like, I need help, but how do you get that help?

And I do think one helpful question that I start to, I’ve used now when people show up at my memory center, particularly if they show up alone, which more and more people are, is, well, you know, who’s that person who’s available, reliable, and trustworthy? And if they say, oh, it’s my whatever. Okay. Well, let’s talk about how we might want to get that person coming to your next visit, for example.

Alex 41:35

Yeah.

Jason 41:36

Or meeting with a social worker who I happen to have who can help. But if there’s, you know, there isn’t someone, that to me is a problem right up there with an LDL of 400, you know, a bone mineral density of whatever. I mean, it is a problem that needs to be addressed, which is I don’t have anyone who’s available, reliable, and trustworthy because you’re going to need that. Yeah.

Eric 41:55

I love that because so much, like you said, Jason, so much of our future healthcare is going to be determined by our wealth. Like, it’s just the US healthcare system. It is what it is.

Jason 42:05

Yeah.

Eric 42:05

And maintaining some financial security is important for health, particularly brain health. Well, with that, Duke, do you want to give us a little bit more Tom Petty? Yeah. Yeah.

Duke 42:15

(singing)

Eric 42:41

Duke, Laura, and Jason, thanks for being on this podcast.

Lauren 42:44

Thanks for having us.

Eric 42:45

We’ll have links to all of the papers we discussed in the show notes, so check out geripal.org to check it out. And again, thank you listeners for your continued support.

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