By Judd Matsunaga, Esq.
Did you know that as a Medicare beneficiary, you are entitled to receive a “wellness visit” every 12 months? Furthermore, it’s free!
However, even though there’s no out-of-pocket expense, only 60% of Medicare beneficiaries had an annual wellness visit (AWV) in 2022 (according to Centers for Medicare & Medicaid Services). A primary reason for low uptake is widespread confusion about what an AWV actually is.
Many people mistake the AWV for a traditional physical exam, which Medicare does not cover. Unlike a traditional physical, the AWV does not include a head-to-toe examination, diagnostic tests, or time to discuss existing illnesses. This distinction can frustrate patients who expect an examination and have specific health concerns they want addressed.
The AWV is designed to create or update a personalized prevention plan, focusing on identifying health risks and making lifestyle recommendations.
Medicare AWVs are crucial for spotting health issues early on, such as high blood pressure, diabetes, and cancer. Going to these visits regularly helps keep you healthier for longer by catching these issues before they get worse by creating a personalized prevention plan.
Early detection allows for early action, which can help manage symptoms and improve your life quality. Without these regular checks, any decline in mental function might not be noticed until it’s more serious.
However, these AWVs are entirely voluntary. You have the legal right to refuse an AWV, and skipping your AWV will not affect your coverage or benefits. Some Rafu readers (especially men) believe in only visiting the doctor when they feel sick or have a specific health issue, rather than for preventive care. Skipping your AWV might not seem like a big deal since it won’t impact your Medicare coverage, but you might miss out on valuable health insights and preventive measures.
Many men will skip their Medicare AWV because they’re afraid that they won’t be able to remember the three unrelated words the doctor is going to ask them to repeat. The “three-word recall test” is a key component of the Mini-Cog – quick screening for early dementia detection.
In other words, many Medicare patients don’t want the doctor to note “cognitive issues” on their medical chart. Or, even worse, to be diagnosed with beginning dementia or Alzheimer’s disease.
Since the AWVs are crucial for spotting health issues early on, such as high blood pressure, diabetes, and cancer, this Rafu article is to help all seniors (male and female) remember those three words so they’ll be more inclined to go to AWVs designed to help them live a longer, healthier life.
Even if you fail such a test, it does not mean you have dementia. But it does “signal” that there might be a problem with short-term memory that should be checked by a doctor.
Do you think the doctor makes up those three unrelated words? And that the three words you are given are different from the previous patient the doctor just saw? Absolutely not – too much work for the doctor.
Furthermore, what if the doctor couldn’t remember the three words? I could be wrong (although highly unlikely), but the three unrelated words that the doctor will most likely ask you to repeat come right out of the Mini-Cog exam. They are “banana, sunrise, chair.”
The phrase “banana, sunrise, chair” is widely recognized as a standard three-word recall test used to assess memory and screen for dementia, such as Alzheimer’s disease. It is part of the Mini-Cog test, which also involves drawing a clock. The doctor will say these three words and then ask you (the patient) to repeat them immediately to ensure that you heard them correctly. After a few minutes, the doctor will ask the patient to recall the three words.
But first, the doctor will try to distract your focus by having you draw the hands on a clock, i.e., the old “clock-drawing task.” After the distraction, the doctor will ask you to repeat the three words. The good news is that the three words don’t have to be repeated in the same order they were given. In other words, if you’re given “banana, sunrise and chair” and repeat them in a different order, that’s OK, you get the same number of points.
Memory experts suggest using the visualization technique by creating an absurd mental story that links the words together. Under the visualization technique, you would connect the words “banana, sunrise and chair” into a single, strange story. The more bizarre and detailed the image, the more likely you are to remember the words, especially after the distraction of the clock-drawing test.
For example, here’s a picture I can visualize — I’m sitting in a beach chair, watching the sunrise, eating a banana for breakfast. Somebody else online suggested imagining a banana peeling itself, floating into the sky to become the sunrise, which then casts a golden chair into the air. If you don’t like either of those, make up your own picture. The more unusual and exaggerated the image, the easier it will be to recall. Focus on vivid details, add sensory details to make the mental picture more concrete.
The test results are not a diagnosis but a preliminary screening. A below-normal score indicates that further evaluation by a specialist is needed. These visits help find health problems early, which can be treated more easily if caught quickly. Without these check-ups, small health issues could become bigger and more difficult to handle later. Going to these visits regularly helps keep you healthier for longer by catching these issues before they get worse.
If you or a loved one have been diagnosed with Alzheimer’s disease or a related dementia, taking steps now can help prepare for a smoother tomorrow. Over time, the symptoms of Alzheimer’s and related dementia will make it difficult to think clearly. Planning as early as possible enables you to make decisions and communicate those decisions to the right people. During this difficult time, consider updating your estate planning documents as soon as possible to protect your wishes before things get worse and it’s too late.
So here’s the “million-dollar question” — can a person diagnosed with dementia or Alzheimer’s still update a trust? The short answer is yes, but with significant caveats. Although I’ve said this before in previous Rafu Shimpo articles, it bears repeating: Diminished capacity is NOT lack of capacity. There are varying levels of legal capacity as defined by the law. While trust creation requires a higher level of legal capacity, changing an already established trust is less burdensome.
For someone with dementia, amending a trust only requires the same showing of capacity as you need to draft a last will and testament. California law Probate Code Section 6100.5 governs the capacity for will creation. Anyone 18 years or older can sign their last will and testament or execute a trust amendment as long as they:
(1) Understand the nature of their property
(2) Know the relationship they have with their relatives and beneficiaries
(3) Can understand the general extent of their assets and wealth.
In simpler language, according to California law, even if Mom and/or Dad have been diagnosed with dementia or beginning Alzheimer’s and can’t remember what they ate for breakfast, they may still have sufficient capacity to amend or update their trust if they know:
(1) They own their home;
(2) They have three children; and
(3) They have money in the bank.
This standard is far less rigorous than what is required to create a legal trust. Therefore, it is always a smart idea to discuss trust creation earlier when there are no questions regarding you or your loved one’s legal capacity. A senior with dementia can create a new trust, provided they still have the legal capacity to undertake such a momentous decision. California law outlines the capacity required for someone to create a trust in Probate Code Section 812.
Simply put, trust creation is a complicated endeavor that is not to be taken lightly. Therefore, California’s probate law requires a grantor to have sufficient mental capacity to understand the actions they are taking. To create a trust, the grantor must have the abilities to understand and appreciate:
(1) The responsibilities created by a trust;
(2) The consequences of creating the trust, for both the grantor and others; and
(3) The inherent risks in trust creation, as well as the reasons to take these risks.
An individual with dementia may not be capable of understanding the long-term consequences of their estate planning choices. Therefore, the probate courts often invalidate documents drafted by someone experiencing an active state of dementia. Waiting too long could lead to legal complications and disputes which could lead to a court appointing a conservator to make decisions for you.
Although a conservator can set up a trust to avoid probate, they must first obtain court approval through a Substituted Judgment Petition — this wastes unnecessary time and money.
At some point, a person with dementia may require around-the-clock care or exhibit behaviors, such as aggression and wandering, that make it no longer safe to stay at home. People who require help full-time can move to an assisted living, nursing home, or residential facility that provides many or all of the long-term care services they need. When planning for long-term care, it may be helpful to think about qualifying for Medi-Cal (Medicaid in other states).
In conclusion, if you or a loved one has recently been diagnosed with dementia or Alzheimer’s acting quickly is essential. As dementia progresses, capacity often declines, so it is crucial to act early, i.e., it doesn’t get any better. Updating your estate plan as soon as you recognize the cognitive decline is critical to ensure your wishes are honored, your assets protected, and family disputes are minimized.
Final thought: When a spouse or other loved one gets diagnosed with dementia, a family member not facing that diagnosis may also need to consider updating their own estate plan. Often, people need to remove a family member with dementia from any position of authority within their estate plans and may even need to restructure how they leave assets to that individual.
Judd Matsunaga, Esq., is the founding partner of the Law Offices of Matsunaga & Associates, specializing in estate/Medi-Cal planning, probate, personal injury and real estate law. With offices in Torrance, Hollywood, Sherman Oaks, Pasadena and Fountain Valley, he can be reached at (800) 411-0546. Opinions expressed in this column are not necessarily those of The Rafu Shimpo.