[Senate Hearing 113-908]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 113-908

                          ALZHEIMER'S DISEASE:
                         A BIG SKY APPROACH TO
                          A NATIONAL CHALLENGE

=======================================================================

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS


                             SECOND SESSION
                               __________

                           BILLINGS, MONTANA
                               __________

                            AUGUST 13, 2014
                               __________

                           Serial No. 113-29

         Printed for the use of the Special Committee on Aging
         
         
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         
         


        Available via the World Wide Web: http://www.govinfo.gov
                       
                       
                              __________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
47-032 PDF                WASHINGTON : 2023                        
                       
                       


                       SPECIAL COMMITTEE ON AGING
                       
                     BILL NELSON, Florida, Chairman

ROBERT P. CASEY, JR., Pennsylvania   SUSAN M. COLLINS, Maine
CLAIRE McCASKILL, Missouri           BOB CORKER, Tennessee
SHELDON WHITEHOUSE, Rhode Island     ORRIN G. HATCH, Utah
KIRSTEN E. GILLIBRAND, New York      MARK KIRK, Illinois
JOE MANCHIN III West Virginia        DEAN HELLER, Nevada
RICHARD BLUMENTHAL, Connecticut      JEFF FLAKE, Arizona
TAMMY BALDWIN, Wisconsin             KELLY AYOTTE, New Hampshire
JOE DONNELLY, Indiana                TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts      TED CRUZ, Texas
JOHN E. WALSH, Montana
                              ----------                              
                  Kim Lipsky, Majority Staff Director
               Priscilla Hanley, Minority Staff Director


                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator John E. Walsh, Committee Member.....     1

                           PANEL OF WITNESSES

Kathleen Burke, Daughter of Alzheimer's Patient, Billings, 
  Montana........................................................     3
George Carlson, Ph.D., Director and Professor, Mclaughlin 
  Research Institute, Great Falls, Montana.......................     5
Patricia Jay Coon, M.D., Billings Clinic, and Co-Chair, Montana 
  Alzheimer's-Dementia Work Group, Billings, Montana.............     8
Bruce Finke, M.D., Elder Health Consultant, Indian Health 
  Service, and Representative to the Advisory Council on 
  Alzheimer's Research, Care, and Services, Billings, Montana....    11

                                APPENDIX
                      Prepared Witness Statements

Kathleen Burke, Daughter of Alzheimer's Patient, Billings, 
  Montana........................................................    27
George Carlson, Ph.D., Director and Professor, Mclaughlin 
  Research Institute, Great Falls, Montana.......................    32
Patricia Jay Coon, M.D., Billings Clinic, and Co-Chair, Montana 
  Alzheimer's-Dementia Work Group, Billings, Montana.............    35
Bruce Finke, M.D., Elder Health Consultant, Indian Health 
  Service, and Representative to the Advisory Council on 
  Alzheimer's Research, Care, and Services, Billings, Montana....    39

                       Statements for the Record

Testimony of Max Richtman, President and CEO, National Committee 
  to Preserve Social Security and Medicare.......................    51

 
                          ALZHEIMER'S DISEASE:
                         A BIG SKY APPROACH TO
                          A NATIONAL CHALLENGE

                              ----------                              


                       WEDNESDAY, AUGUST 13, 2014

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 a.m., in the 
South Park Senior Center, 901 South 30th Street, Billings, 
Montana, Hon. John E. Walsh, presiding.
    Present: Senator Walsh.

                 OPENING STATEMENT OF SENATOR 
                JOHN E. WALSH, COMMITTEE MEMBER

    Senator Walsh. Good morning. I want to welcome everyone to 
this Senate Special Committee on Aging field hearing. I thank 
all of you for taking time out of your busy schedule to be here 
with us today and to discuss this very important topic.
    I would like to start by thanking Dolores Terpstra and the 
board of the South Park Senior Center for your generosity in 
sharing this space. Thank you very much.
    I would also like to thank Bea Ann Melichar, who is the 
Executive Director of the Adult Resource Alliance, and her 
staff, for all your work. Bea, thank you very much.
    I would also like to thank the Alzheimer's Association, and 
especially the Montana Director, Heidi Gibson--where is Heidi 
at? All right. Heidi, thank you for all the help that you have 
done to provide for this field hearing. The Alzheimer's 
Association does great work to educate and support families 
dealing with this difficult disease. They will be hosting a 
number of events across the State the next month to raise 
awareness and money to help find a cure, so, if you are able to 
participate in a Walk to End Alzheimer's event, I encourage you 
to do so.
    I will start off with a little bit of housekeeping for this 
hearing. I want everyone here to be part of the conversation. 
My staff have distributed comment cards that we hope you will 
use to ask your questions for our witnesses. Just fill it out 
during this hearing and pass it to one of my staff. If my staff 
would please raise your hands so you can see who they are. We 
may not be able to get to all the questions during this 
hearing, but I will make sure your questions for the witnesses 
are submitted for the record so they can be answered after the 
hearing.
    We have a great line-up of witnesses with us today and I am 
looking forward to hearing from each one of you. Thank you for 
being here with us.
    Dealing with Alzheimer's disease is a tremendous challenge. 
This is especially true in a rural State like Montana, where 
great distances can make it difficult to access community 
resources, so, it is crucial that we tackle the challenge head-
on. Perhaps the most important goal of this field hearing is to 
raise awareness about the disease and to help reduce the stigma 
associated with Alzheimer's.
    Alzheimer's disease is not a normal consequence of aging. 
It is estimated that half of all Americans with Alzheimer's 
disease have not been diagnosed, and, even among those who are 
diagnosed, many are not aware of the resources that are 
available to them when it is identified. If you or someone you 
love has Alzheimer's disease, I encourage you to get in touch 
with the Alzheimer's Association or your nearest Area Agency on 
Aging or another local support group for more information.
    As our population ages, Alzheimer's disease is affecting 
more and more families across the State of Montana. Today, 
there are about 18,000 Montanans suffering from the disease. 
That number is projected to surge to around 27,000 in the next 
10 years. This is clearly a growing problem that will only 
become more severe as our population ages.
    Alzheimer's disease not only affects those with the 
disease, but it can cause a tremendous financial, emotional, 
and even physical toll for family members and other caregivers. 
There are about 48,000 people in Montana who care for someone 
with Alzheimer's disease or other dementias. Many of these 
unpaid caregivers cut back hours of work or quit their job in 
order to take on the responsibility of care. The Alzheimer's 
Association estimates that the value of unpaid care in Montana 
reached a staggering $677 million in 2013. That number is only 
rising, and it does not include the considerable emotional toll 
associated with the disease.
    Research also shows that this disease particularly affects 
women. More than 60 percent of unpaid caregivers for someone 
with Alzheimer's disease are women. In addition, roughly two-
thirds of people who develop Alzheimer's disease are women, so, 
this disease is equally harmful for both men and women, but 
women are disproportionately affected, largely because women 
live longer than men. Researchers have shown that older age is 
the greatest risk factor for this disease.
    There is no doubt that this is a devastating disease. 
Symptoms develop slowly at first, but this disease steadily 
disrupts neural networks and overtakes a person's ability to 
perform basic tasks. This disease can literally cause the brain 
to shrink from a healthy three pounds to only one pound. In the 
process, people with Alzheimer's lose their ability to take 
care of themselves and can even lose the ability and capacity 
to recognize members of their own family. It is truly agonizing 
for loved ones in this situation.
    I am working with my colleagues to strengthen the Federal 
commitment to Alzheimer's research and to help ensure that 
families have the resources that they need, and, I am proud to 
cosponsor the HOPE Act. This bill will ensure that families 
will have access under Medicare for not just a diagnosis, but 
also information and other services to help navigate the 
disease. I have also cosponsored the Alzheimer's Accountability 
Act that would require the Director of the National Institutes 
of Health to submit an annual budget to meet the goal of 
preventing and treating Alzheimer's disease by the year 2025.
    If you or a loved one is dealing with Alzheimer's disease, 
the message I hope you get from this field hearing is that you 
are not alone. There are many talented people in Montana who 
are working hard to educate and support caregivers.
    One of those people here is here with us today in Billings, 
is Kathleen Burke. Both of Kathleen's parents served their 
country during World War II. They were decorated for their 
service in the European and African Theaters while stationed on 
a hospital ship in the Mediterranean Sea. Both, unfortunately, 
developed Alzheimer's disease. Kathy knows firsthand the 
tremendous challenges of caring for parents with Alzheimer's. 
Kathy has drawn from her experience to be an advocate in this 
community and she is a member of the Montana Alzheimer's 
Association Board of Directors. She is also the Caregiver 
Representative for the Montana Alzheimer's Working Group.
    Today, I have asked the witnesses to limit their testimony 
to approximately five minutes each, and, with that, Kathy, we 
would like to hear from you. Thank you, Kathy, for being here.

             STATEMENT OF KATHLEEN BURKE, DAUGHTER 
           OF ALZHEIMER'S PATIENT, BILLINGS, MONTANA

    Ms. Burke. Good morning. Senator Walsh, individuals who 
recommended my participation, fellow panelists, audience 
members, thank you for this vital hearing. It was with a 
humbling sense of responsibility that I accepted the invitation 
to testify and bring a common face to Alzheimer's. I apologize 
ahead of time for speed-reading my testimony, but I am 
concerned about the time and do not want to miss points, 
especially educational ones.
    My name is Kathleen Burke, and unfortunately, I have a 
family history of Alzheimer's and related brain disorders on 
both sides of my family for at least two generations. I helped 
my maternal grandparents when I was the only relative within 
900 miles. I resumed caregiving when my mother, Shirley, was 
diagnosed with Alzheimer's in 2002, and my father, Jack, in 
2010. My mother has been in a nursing home since January 2013 
due to her Alzheimer's, now in its final stages. My father, who 
was on medication for his mild symptoms of Alzheimer's, died 
last September of pancreatic cancer.
    I am honored to speak on behalf of the estimated 48,000 
caregivers for the 18,000 Montanans currently diagnosed with 
Alzheimer's disease. The number of Alzheimer's patients is 
projected to increase in Montana by 50 percent by 2025. This is 
a startling forecast that we need to derail. When the 
government provides to Alzheimer's disease the level of support 
that has been given to cancer and heart disease research for 
the last 40 years, tremendous strides should also be 
accomplished for Alzheimer's.
    The Alzheimer's Association provides this list of ten 
warning signs that can be used as a checklist to discuss 
concerns with medical providers. The signs are: Memory loss 
that disrupts daily life; challenges in planning or solving 
problems; difficulty completing familiar tasks at home, at 
work, or at leisure; confusion with time or place; trouble 
understanding visual images and spatial relationships; new 
problems with words and speaking or writing; misplacing things 
and losing the ability to retrace steps; decreased or poor 
judgment; withdrawal from work or social activities; and 
changes in mood and personality. According to the 2014 
Alzheimer's Disease Facts and Figures report, the personal 
difficulties that I will mention now are experienced by many 
Alzheimer's families.
    Personality changes are common and can cause rifts in 
families if one does not remember that the disease adversely 
affects the person who used to know and relationships with 
them. I had to interrupt a class to deliver a message to a 
student about his parents in Great Falls. His Alzheimer's 
afflicted father had beaten his mother so severely that she was 
taken to the hospital and his father was arrested.
    Mom put an appointment on the calendar, but did not know 
why. I took off work and found a salesman discussing plots in a 
veterans' section of a local cemetery, so my parents thought it 
was free for vets. I recognized the salesman, mentioned Mom's 
Alzheimer's, and explained that they would not be buying.
    Mom was baking a frozen pizza for supper with the plastic 
wrap still on it. She said she always did it that way. Since it 
was no longer safe for her to cook and Dad did not know how, I 
had to solve the problem, which included in-home help costing 
$20 to $25 an hour in this area.
    Mom was dropped off at a casino to play cards, but Dad 
remembered the wrong day, so her friends were not there. Rather 
than thinking to phone family members, she accepted a ride from 
a complete stranger to take her home. That was pretty shocking.
    I would call Mom daily to ask if she had taken the pills 
set up for her and if she dressed. I started to find chewed 
gelatin pills in the garbage and on the floor. One day, she had 
two shoes of different colors, whereas another time she had on 
two right loafers. One night when I saw her limping and asked 
why, she did not know. I took off her shoe and found a sock 
crammed in the toe of her shoe. Dad was angry when I suggested 
he had to pay more attention when helping. His typical response 
was, ``You do not understand.''
    When Dad had a brain abscess in 2007, I had to take Mom to 
work with me because I could not safely leave her by herself. 
It was difficult to find senior day care in Billings then. It 
is still limited, and may require a contract as opposed to 
meeting drop-in needs. The client has to be quite independent, 
but it is still cheaper than in-home care. My brother was 
fearful that my Dad's wanting to save money by taking care of 
Mom at home instead of using the nursing home would take a toll 
on Dad's failing health, which happens to caregivers.
    Driving is a huge issue for Alzheimer's victims and their 
families. After twelve years of discussing it at caregiver 
meetings, I can remember only three people who gave up driving 
on their own, which was not the case for my Dad.
    I had four experiences where Mom's increased confusion in 
unfamiliar surroundings, coupled with lack of Alzheimer's 
knowledge on the part of physicians and nurses, made for 
miscommunication and injury. This points out that Alzheimer's 
education is needed for everyone, including medical personnel, 
to meet the needs of these patients. Employers are another 
group for which education would improve understanding as to why 
employees need to be gone from work for caregiving for family 
members with Alzheimer's.
    At the end of their 68th wedding anniversary celebration in 
the nursing home on July 4, 2013, Mom pushed Dad away when he 
bent over to kiss her goodbye, saying that her husband would 
not like that. It was difficult for me to see, but probably 
worse for him, since he would not talk about it. He was 
diagnosed with pancreatic cancer in August and did not visit 
her after that, knowing that she would not understand. It still 
hurt not to be able to tell her that her husband died of cancer 
and that his funeral was one day before her 91st birthday.
    I considered retiring early so I could take care of Mom, 
but realized it is a 24/7 job for which there is not enough 
support. Her disease does not allow her to speak many words. 
She has eating challenges and is confined to a wheelchair. I 
visit her daily, but she usually does not realize who I am. I 
miss both my parents, the one who died physically and one who 
has almost died mentally.
    In closing, thank you for letting me testify. With proper 
funding, I am looking forward to what can be done with 
Alzheimer's funding to prevent the terrible Montana forecast 
from becoming a reality.
    Senator Walsh. Thank you, Kathy, very much.
    Again, if you have questions for the panel, please pass 
them to my staff, and so what we will ask you to do is pass 
them over to the outside of the aisle, and my staff will 
collect the questions and we will make sure that they get 
asked, based on our timing.
    Next, we will hear from George Carlson. George is the 
Director of the McLaughlin Research Institute, a nonprofit 
organization in Great Falls, Montana. George joined the 
McLaughlin Institute in 1988 and has overseen an expansion of 
the facility. Dr. Carlson is the 2014 inductee of the Montana 
Bioscience Hall of Fame. I am proud to have supported the 
McLaughlin Institute as Lieutenant Governor, and I will 
continue to support the Institute as a U.S. Senator for the 
State of Montana.
    Dr. Carlson, you may begin. Thank you.

          STATEMENT OF GEORGE CARLSON, PH.D., DIRECTOR

               AND PROFESSOR, McLAUGHLIN RESEARCH

                INSTITUTE, GREAT FALLS, MONTANA

    Dr. Carlson. Thank you, Senator Walsh, for providing me 
this opportunity to testify today on behalf of the McLaughlin 
Research Institute, and more importantly, on behalf of the 
people of Montana who are or will be afflicted by Alzheimer's 
and related dementing illnesses.
    As you know, MRI is an independent, nonprofit research 
organization in Great Falls, and we conduct basic biomedical 
research to try to understand and, ultimately, prevent 
neurodegenerative diseases like Alzheimer's, Parkinson's, and 
related disorders. I thank you, Senator Walsh, for recognizing 
the looming national crisis that will be caused by Alzheimer's 
and other dementias as our population ages.
    The personal tragedy of dementia, that you just heard one 
example, cannot be fully comprehended by those whose family 
members have been spared. The suffering caused by Alzheimer's 
is reason enough to expand our efforts to prevent this illness. 
Unfortunately, the economic impact of dementing diseases also 
is immense.
    Currently, according to the Alzheimer's Association, five 
million Americans and as many as 25,000 Montanans, if you 
include all dementias, are currently afflicted, with an annual 
financial cost to the country approaching $100 billion. By 
2050, if nothing changes, as many as 16 million Americans could 
be affected, costing the economy $1.2 trillion. However, 
investment in research can bend this cost curve.
    The effectiveness of biomedical research, which is funded 
largely by the National Institutes of Health, is unquestioned. 
Progress against cancer and heart disease over the past 50 
years, to name only two examples, has been remarkable. For 
example, the impact of statins, which were developed based on 
fundamental basic research, on lowering the risk of coronary 
artery disease and heart attacks is well known.
    In contrast, Alzheimer's was identified as a disease over 
100 years ago and there are still absolutely no therapies 
capable of even slowing its inexorable course. It is telling 
that for every $28,000 the Federal Government spends on caring 
for patients with dementias, only $100 in Federal funds goes to 
support research on these disorders.
    National Institutes of Health funding for Alzheimer's 
disease in 2013 was approximately $412 million, in comparison 
to $3 billion for AIDS research, $2 billion for cardiovascular 
disease, and $5 billion for cancer research. Support for 
research into all these diseases certainly is important, but 
the financial impacts of dementia is now greater than those of 
either heart disease or cancer.
    On the positive side, the Obama administration has 
developed and is implementing a National Plan to Address 
Alzheimer's Disease. Unfortunately, funding is below the levels 
needed to accelerate progress toward the worthy goal of 
developing treatments that would prevent, halt, or reverse the 
course of Alzheimer's disease.
    New approaches developed using mice, by MRI scientists and 
our collaborators, are being used to identify the earliest 
molecular changes in neurodegenerative diseases with the goal 
of finding markers in the blood that can indicate the presence 
of disease processes decades before clinical signs or symptoms 
appear. Although there is no treatment now, future therapeutic 
interventions are much more likely to be successful in the 
early stages of disease.
    We also are beginning to understand the mechanisms for the 
prion-like spread of Alzheimer's disease pathology within the 
brain, potentially offering a new way to intervene in the 
disease process. The way disease spreads from one region of the 
brain to another is similar for Alzheimer's and Parkinson's 
disease as well as for chronic traumatic encephalopathy, which 
arises from traumatic brain injury and has been found in our 
troops returning from Iraq and Afghanistan, so, this is a 
separate health crisis. The cost of the war does not end when 
the troops withdraw.
    We understand more about Alzheimer's and other dementive 
disease than ever before, and our research is at a pivotal 
point. It is largely a matter of our elected representatives 
deciding that a cure is worth funding. At the same time that 
science is close to making a difference for people who will 
suffer dementing disorders, Federal funding for medical 
research is drying up.
    We at McLaughlin are starting an exciting new initiative to 
speed up the translation of basic research findings into 
medical practice. We are collaborating with Benefis Health 
System in Great Falls to develop a Center for Aging Research 
and Memory Care, a unique partnership between an excellent 
community hospital and an internationally recognized research 
institution. This ``center without walls'' is not a place, but 
an exciting new initiative aimed at improving patient care now 
and in developing new avenues to search for ways to prevent 
disease.
    As only one example, we will transplant stem cells from 
Alzheimer's patients into mice to watch the progression of 
disease in a living brain, providing a new tool to test 
potential therapies and giving us real hope for a cure.
    With Federal support shrinking, the State of Montana 
stepped up with a grant of nearly $1 million in 2014 as seed 
money for this Center for Aging Research and Memory Care, and, 
I would like to thank you, Senator Walsh, for your support of 
this appropriation when you were Lieutenant Governor.
    Americans also recognize that our Nation's global 
leadership in science is tenuous. Our leadership position will 
evaporate if policymakers shortchange government support for 
basic research. Unlike the U.S., countries like China and India 
are rapidly increasing their investments in science. MRI 
scientists are now receiving funding from India's National 
Center for Biological Sciences to help establish a mouse 
genetics facility and lab in Bangalore. While this 
international collaboration is exciting, I had never imagined 
that our research in Montana would be supported by funds from a 
developing country.
    To maintain America's leadership in biomedical research, as 
well as find ways to prevent dementia and other devastating 
diseases, it is essential that talented young people pursue 
scientific careers. We at MRI have observed first-hand 
decisions by talented post-doctoral trainees discouraged by the 
downturn in grant application success rates to abandon basic 
research for careers that offer more security.
    If Congress and the administration let funding for 
Alzheimer's and related disorders stagnate as inflation further 
eats away at its value, we will compromise progress at a time 
our health care system and the Nation can least afford it. 
Discoveries made at MRI and research organizations across the 
country have set us on the road to finding a way to prevent or 
cure dementing illness. It is essential to enhance Federal 
support for Alzheimer's disease research.
    Thank you, Senator Walsh, for this opportunity to testify 
on behalf of the research community, and more importantly, on 
behalf of families affected by dementing illness.
    Senator Walsh. Thank you, Dr. Carlson. Thanks for the work 
that you and MRI are doing. We really appreciate it.
    Next, we have Dr. Patricia Coon. Dr. Coon is a geriatrician 
at the Billings Clinic and will serve as the Co-Chair of the 
Montana Alzheimer's/Dementia Work Group that will develop a 
State plan for dealing with this disease. She is also on the 
Board of Directors of the Billings Clinic Foundation.
    Dr. Coon, the floor is yours.

         STATEMENT OF PATRICIA JAY COON, M.D., BILLINGS

           CLINIC, AND CO-CHAIR, MONTANA ALZHEIMER'S-

             DEMENTIA WORK GROUP, BILLINGS, MONTANA

    Dr. Coon. Thank you. Good morning, Senator Walsh, fellow 
speakers, and members of the audience. As you have heard, I am 
Patricia Coon, a physician who has practiced geriatric medicine 
for nearly 30 years, the majority at the Billings Clinic in the 
frontier State of Montana. I also serve as the Co-Chair of the 
Montana Alzheimer's/Dementia Work Group, a statewide work group 
established this year with the goal of improving the lives of 
individuals in Montana with Alzheimer's and other dementias and 
to provide better support for the families and caregivers. It 
is an honor to be here to speak for that group today to discuss 
our efforts and the challenges we face caring for individuals 
with this devastating disease.
    I think we have to--I always have to frame the dialog. 
Alzheimer's disease is likely one of the most significant 
public health crises of our generation. It is a progressive and 
ultimately fatal neurologic disorder and is the sixth leading 
cause of death in the United States, but, unlike the other top 
ten leading causes of death in our country, for example, heart 
disease and cancer, it is the one without a way to prevent it 
or cure it. There is no effective treatment. Yet, at present, 
Federal funding for Alzheimer's disease research is 
substantially less than for cancer and cardiovascular research. 
As a health care provider and a resident of the U.S., this is 
very concerning to me for the following reasons.
    Alzheimer's disease is already a common disorder. 
Currently, more than five million Americans are living with 
this incurable disorder. The disease is estimated to--the 
number is estimated to triple by 2050. In Montana, as you 
mentioned, Senator, 11 percent of our seniors are living with 
this disease. Given the slow, insidious nature of the disease, 
on average, individuals with Alzheimer's survive four to eight 
years after diagnosis. Some live as long as 20 years. Much of 
this time is spent with significant mental and physical 
disability and dependence.
    Not surprisingly, Alzheimer's disease takes a significant 
toll on caregivers and families, physically, emotionally, and 
financially. Patty Davis described losing her father, President 
Reagan, to Alzheimer's disease as ``the long goodbye.'' 
Families and friends say goodbye to an individual slowly over 
time as the disease gradually steals away his or her memory and 
other cognitive functioning. In the most severe stage of the 
disease, nursing home placement is almost inevitable, and I 
think Kathy has shared that with us.
    The financial burden of Alzheimer's disease and other 
dementias is high at an individual, family, State, and national 
level. It is the costliest chronic disease in our society. It 
is estimated that the national cost of caring for people with 
Alzheimer's and other dementias will reach $214 billion in 
2014, this year. Of those costs, 70 percent of it is absorbed 
by Medicare and Medicaid. The out-of-pocket spending for 
individuals with dementia and their families is estimated to be 
$36 billion this year.
    The national annual cost for caring for these individuals 
is projected to reach $1.2 trillion, with a ``T'', by 2050. 
Unless we change the trajectory or course of this disease, the 
economic burden stands to overwhelm us all. I applaud the steps 
the Federal Government has taken in recent years to address 
this, including Congress passing the National Alzheimer's 
Project Act, which led to the creation of the National Plan to 
Address Alzheimer's Disease in 2012. The plan is designed to 
help those with the disease, their families, and caregivers 
today and work toward changing the trajectory of the disease in 
the future, but, more is needed if, as a Nation, we want to 
prevent and effectively treat the disease by 2025.
    Now, our efforts in Montana. While working toward changing 
the course of the disease in the future, we need at a 
community, State, and national level to deliver better care and 
support to individuals suffering with this disease and their 
families and caregivers today. I continue to see the 
devastating effects of Alzheimer's disease and dementia on my 
patients and their families. I have watched the health care 
industry and patient advocacy groups struggle to provide the 
comprehensive quality care and services these individuals and 
families require and deserve.
    Given the slow progressive nature of the disease with its 
associated cognitive and physical disability and its associated 
psycho-social issues--that is the behavioral issues--it will 
take a village to accomplish this. We need to develop effective 
dementia-capable systems at the health care organization level 
and the community and State levels and find new strategies to 
provide high-quality coordinated care, services, and programs 
to these individuals and their families and caregivers.
    To help achieve this here in Montana, a number of concerned 
and motivated individuals--Dr. Carlson and Kathy are part of 
that--have formed the Montana Alzheimer's/Dementia Work Group. 
This statewide grassroots effort consists of a diverse group of 
individuals from across the State representing multiple 
industries or stakeholder groups, including the Alzheimer's 
Association, the Montana Office on Aging, and other government 
agencies, patient advocacy groups, caregivers, senior services 
groups, et cetera.
    The Work Group has established itself with identifying the 
challenges and gaps--has tasked itself with identifying the 
challenges and gaps Montanans face when dealing with this 
disease and estimating its economic impact on our State. Using 
this information, over the next 12 to 18 months, we plan to 
develop a comprehensive Montana Alzheimer's Disease Plan, 
similar to what we see from the Alzheimer's Association. This 
plan will serve as a roadmap specific for Montana to help 
inform our State government on critical dementia issues. It 
will also provide a set of recommendations on how to implement 
and support Alzheimer's disease care and services and will 
outline what steps our State should take over a given timeframe 
to achieve key recommendations.
    Given the current and future impact of Alzheimer's disease 
on our State's budget, particularly Medicaid, we feel that 
developing and implementing a well-formulated State plan now 
will move Montana toward becoming a dementia-capable State and 
prepare us for the sweeping economic and social impact 
Alzheimer's disease will have on us going forward.
    To be prepared for the Alzheimer's disease public health 
crisis, Montanans face the same challenges as other States. 
Alzheimer's can no longer be the silent or hidden disease. 
Statewide, we need to increase public awareness about it and 
encourage early detection and diagnosis. We need to deliver 
community-based and residential care services in an equitable, 
cost effective manner. There needs to be better support for 
family caregivers to help alleviate their burden. Training 
programs for all caregivers, for example, physicians, nurses, 
emergency room personnel, with a standardized curriculum needs 
to be developed to ensure providers have the skills necessary 
to deliver coordinated, quality dementia care. In partnership 
with our Federal and State governments and key stakeholders, we 
need to create dementia-friendly communities that locally 
provide high-quality coordinated care, services, and programs 
to individuals with Alzheimer's and their families.'
    Montana also faces unique challenges. Given its large land 
mass and small population, it is not only a rural State, but a 
frontier State. Rural and frontier communities struggle to 
recruit and retain primary care providers, who do the lion's 
share of the work with these individuals. They lack the 
community-based and residential dementia care services found in 
larger communities. For decades, one of our State's biggest 
exports has been its youth. This affects the availability of 
local family support to help somebody afflicted with the 
disease. To ensure their care needs are met, many will need to 
be admitted to a local nursing home, a high-cost place, or 
leave the community to be closer to family. There is also a 
shortage of geriatric specialists across the State. Our Work 
Group and State will need to consider these unique challenges 
as we develop and implement an Alzheimer's Disease State Plan.
    In conclusion, I would like to thank you and the Committee 
again for the opportunity to testify today and talk about the 
Montana Alzheimer's/Dementia Work Group initiative. I 
appreciate your interest and efforts to address Alzheimer's 
disease going forward. It is clearly a prevalent, costly, 
devastating condition with high morbidity and mortality. If the 
course of the disease is not altered, by mid-century, the 
economic and societal impact of this disease on all of us will 
be overwhelming. Likely, all of us and our children will be 
impacted by it.
    Working in partnership, we all need to do what is necessary 
to achieve the goal of the National Plan to Address Alzheimer's 
Disease, to prevent and effectively treat Alzheimer's disease 
by 2025. As a physician who provides medical care for these 
individuals, I look forward to the day when I can offer truly 
effective preventive treatment options to my patients and 
family, such as I wish I could for Kathy's mother, and I would 
like to do going forward for Kathy, for example.
    Thank you again for your time on this.
    Senator Walsh. Thank you, Dr. Coon.
    Again, this is a very difficult disease to deal with, and 
we are seeing a lot of discussion here, but, again, we want 
participation from the audience, so if you have questions, 
please pass them over to your left or right, to the end of the 
aisle, and my staff will pick them up and we will make sure 
that we get those questions asked.
    Next, we have Dr. Finke. Dr. Finke is a family physician 
and geriatrician and serves as a national leader in elder care 
and palliative care for the Indian Health Service. He is the 
Indian Health Service Representative to the National Advisory 
Council on Alzheimer's Research, Care, and Services. He now 
works with Tribes in the Nashville area and nationally in the 
develop of health care services for elders.
    Dr. Finke, please.

          STATEMENT OF BRUCE FINKE, M.D., ELDER HEALTH

               CONSULTANT, INDIAN HEALTH SERVICE,

               AND REPRESENTATIVE TO THE ADVISORY

                COUNCIL ON ALZHEIMER'S RESEARCH,

             CARE, AND SERVICES, BILLINGS, MONTANA

    Dr. Finke. Good morning, Senator Walsh. As you said, I am 
Dr. Bruce Finke, Elder Health Consultant for the Indian Health 
Service, and I am very pleased to be able to be with you today.
    On a personal note, I very much grew up as a caregiver for 
my beloved grandfather, who had dementia, as well.
    In every Tribal community, there are individuals with 
dementia and caregivers struggling to support them. IHS 
population health data and workload statistics confirm this, 
and, the high rates of diabetes, cardiovascular disease, and 
traumatic brain injury suggest additional population risk for 
dementia. It is likely that dementia is under-recognized and 
diagnosed at later stages in Tribal communities, even relative 
to the low rates of diagnosis in the Nation as a whole.
    Clinical care for persons with dementia and support to 
their families requires significant care management and 
coordination, resources often beyond the capacity of tribal IHS 
and urban health programs. Caregiving challenges for families 
in Indian Country are amplified by the relative lack of formal 
long-term care services.
    Over the years, Tribes have been the lead in the 
development and provision of these services. The Indian Health 
Care Improvement Act Reauthorization in 2010 provided IHS and 
Tribes with new authorities for the services, but so far, these 
authorities have not received funding, and the capacity of 
local Tribal and Federal care systems to expand access to long-
term services and supports remains a significant challenge.
    As others have mentioned, in January 2011, President Obama 
signed into law the National Alzheimer's Project Act, NAPA, 
requiring the HHS Secretary to establish the National 
Alzheimer's Project, including a national plan to overcome 
Alzheimer's disease and an advisory council to inform that 
plan. This plan includes a detailed listing of current Federal 
activities and recommendations for priority actions. The April 
2014 plan update describes the progress made to date in the 
areas of research, care and support, and interagency 
collaboration.
    Through the National Plan, the IHS is working with the 
Administration for Community Living and the Administration on 
Aging around four person-centered goals for improving the care 
for and the lives of American Indians and Alaska Natives with 
dementia and their families. These goals are expressed as 
statements that every individual with dementia should be able 
to make. I was diagnosed in a timely way. I know what I can do 
to help myself and who can help me. Those helping to look after 
me feel well supported, and, my wishes for care are understood 
and honored.
    Our work on these four goals builds on Indian Country 
strengths: Strong families and a tradition of family 
caregiving; community-oriented primary care; committed and 
active public health nursing and community health 
representatives; and the Tribally operated aging network.
    To improve the lives of those with dementia, we are 
partnering with Tribes and across Federal agencies and bridging 
the usual boundaries of clinical and community-based services. 
Some examples: The IHS and Administration for Community Living 
are working with the VA to adapt and implement the evidence-
based REACH VA model of caregiver support, using both public 
health nursing on the clinical side and the Tribal aging 
network through the senior centers. The VA is a terrific 
resource for programmatic expertise in dementia and, 
importantly, also provides clinical expertise in diagnosis and 
management of dementia for many of the Native veterans who 
receive primary care in the IHS and Tribal sites.
    Most care for persons with dementia can and should take 
place in primary care. IHS Tribal and urban clinics are 
improving access and continuity and enhancing care management 
coordination for our Improving Patient Care program, a primary 
care medical home initiative. In recent years, increased 
funding for purchased and referred care, formerly contract 
health services, has increased access to the specialty services 
that support this primary care.
    Tribes continue to take the lead in the development and 
provision of long-term services and supports, and under a 
Memorandum of Understanding signed in 2011, the IHS, 
Administration for Community Living, and CMS, the Centers for 
Medicare and Medicaid Services, regularly coordinate and have 
developed meetings, webinars, and web-based technical 
assistance resources to support these Tribal efforts.
    Increasing awareness and recognition of dementia in Indian 
Country starts with access to quality care and meaningful 
support for individuals with dementia and their caregivers in 
Indian Country. The IHS is committed to working in partnership 
with Tribes, Federal agencies, and community organizations to 
provide individuals with dementia and their families with the 
best possible care.
    Thank you, and I am looking forward to questions and 
conversation.
    Senator Walsh. Thank you, Dr. Finke.
    Finally, our last guest was not able to make it today due 
to weather. It was Mr. Max Richtman, who is the President and 
CEO of the National Committee to Preserve Social Security and 
Medicare. He had flight troubles due to weather yesterday 
coming out of the D.C. area, but, his prepared testimony will 
also be entered into the record.
    The hearing record for this meeting will remain open for 
five business days for additional statements and post-hearing 
questions submitted in writing for our witnesses to answer.
    This will conclude the official part of our hearing. I am 
going to now gavel out, and I will move to questions that we 
have received from the audience.
    The first question that we have is from Nita to Dr. Coon. 
What are State legislators doing to improve financial 
commitment to assisted living and nursing home placement for 
seniors?
    Dr. Coon. It is a very good question, and unfortunately, I 
do not have an answer to it, because as not being a State 
legislator, I am not involved in that process. I do not have 
any answer. I do not know if, Dr. Carlson----
    Dr. Carlson. No, I do not.
    Dr. Coon. One of the things that we do as we do our--the 
Work Group moves forward and makes our State plan, it will be 
vetted and then it will actually be presented to the State 
legislature, so, if people do have some questions or concerns, 
or if they also have some potential solutions for what they 
perceive, it would be great to get it to us so we can 
incorporate it into our State plan, or they can join us, 
because we still have an open membership at this point on our 
State Plan Work Group.
    Senator Walsh. Okay. Great.
    Next, this question is for anyone on the panel who feels 
they have an answer. What is being done in other countries, for 
example, the rate of Alzheimer's in the USA versus China, 
versus Europe, and does exercise help or other alternative 
methods help with this disease?
    Dr. Carlson. That is an interesting question, and it is 
something that I think our Task Force should look into. The 
cultural differences are immense. Also, an immense difference 
is single-payer health care, so, the cost--it takes away one 
concern for a family member, which we hope will change in this 
country, as well, is am I insured? I do not know. That is a 
very interesting question. What does France do? Many countries, 
as was alluded to with Tribal Governments, have a tradition of 
in-home caregiving, like India and so on. Even some people in 
India seem to look at dementia as a stage of life and it is 
caring for the family members, but, it is those caregivers are 
removed from society just as much there as anywhere else, so, 
the incidence in the U.S., I do not believe, is any greater, 
other than the increase in incidence of diabetes, which is a 
risk factor.
    Senator Walsh. Dr. Finke.
    Dr. Finke. I would just comment that the National 
Alzheimer's Project Act requires, among other things, that HHS 
look--or, coordinate with international bodies to fight 
Alzheimer's globally, and there is a significant effort through 
that work to coordinate with other nations. On the research 
side, through the National Institutes of Aging, there is quite 
a bit of activity to develop--and the Alzheimer's Association 
actually is a part of that work--to develop a common basis for 
research efforts and a sharing of information across national 
boundaries to facilitate research.
    There has also been quite a bit of sharing. There was a G-
7, G-8 meeting in London over the past couple of years--I am 
not sure of the exact date--at which nations shared their 
approach to addressing Alzheimer's.
    The language that we have--that the Administration for 
Community Living and the Indian Health Service adopted around 
patient-centered goals, in part, comes from language that Great 
Britain has adopted as a way of framing their efforts to 
improve care for persons with Alzheimer's.
    Dr. Coon. I have an answer more on a clinical level than--I 
think it is a great idea for us to look at what other countries 
are doing, in particular, England is doing with regards to this 
disease. I know that as a health care provider, I often go to 
their NICE site, which is the National Institute for Clinical 
Excellence, and they are much more robust in the information 
they provide than we get anywhere else in this country, and I 
think that does need to be something that needs to be 
addressed.
    I want to answer the second question, because I think there 
was something about exercise. You know, we do not have any 
effective treatments. I do want to say, I am one of probably 
the few people that keep referring to it as a chronic disease. 
We do know there are three phases, pre-clinical into mild 
cognitive impairment, and, when people start having problems 
with mental functioning, we actually call it Alzheimer's 
disease, but, it is a continuous disorder, similar to what we 
see for heart disease. Plaque gets laid down. You finally have 
your heart attack. This means plaque and tangles get laid down 
and you finally get the disease.
    Anywhere along that spectrum, we encourage exercise. We 
want to control other risk factors, such as diabetes, 
hypertension, elevated cholesterol, work and do those vascular 
risk factors so that that is not a double-whammy to the brain, 
leading to cognitive impairment, so, I think, exercise is very 
important.
    Also, what I often counsel my patients to do is mental 
gymnastics, and that there are actually three apps available 
for Smartphones. There are also programs available that have 
people go through, and set up by neuropsychologists and 
neurologists have set up these programs that allow people to 
really work on the different domains, whether it is memory, 
visual-spatial, or other areas of the brain that are affected 
by this disease, for them to try to improve it. I know that 
there has been some thought that these programs may actually 
help with working memory in people who have mild cognitive 
impairment.
    Mental gymnastics, physical gymnastics, and controlling 
vascular risk factors are very important, which means lifestyle 
change, which, I think, we hear all the time from our doctors, 
but all of that is very important, so, I hope that answered 
that question that the person was asking.
    Senator Walsh. Any other input on that question?
    Okay. This next question is from Lisa, and it is, again, to 
the panel. What do we believe can be done to help caregivers?
    Ms. Burke. Well, I think we need two things, as a 
caregiver. One, a sense of humor, and I do not think that 
should be underestimated, and patience, and, we need education, 
as I stated before, so many times, the diagnosis comes, and it 
is kind of like when people hear the word ``cancer.'' It is 
like it is a shock and you do not know what to do, where to go 
for help, and, there are all kinds of resources, whether they 
be local ones, whether they be websites, but, I think education 
is primary, not only for the person who has been diagnosed, but 
for their caregivers and for the community as a whole, as I 
mentioned before, because there is a lot of misunderstanding.
    We have--fortunate, in a big city like this, we have 
different caregiver groups. I mean, there are ones through the 
Billings Clinic, ones through the Alliance, ones through 
different nursing homes, and they provide speakers and sharing 
of experiences, like I mentioned, so that caregivers are maybe 
not surprised by the progress or certain situations that come 
past because they know that other people have had them and 
potential ways to help work with them.
    Senator Walsh. Dr. Finke. I am sorry. Go ahead, Dr. Coon, 
first.
    Dr. Coon. You know, I think that there are probably several 
things that we need to do for caregivers. One is education, but 
not only for the caregivers, especially when they are dealing 
with individuals with the significant behavioral issues we see 
with this disease, but we need to have better education of 
health care providers that are working with these individuals, 
nursing home staff, assisted living staff, so that, together, 
they can really address the situation that--the behavioral 
issues and the problems we see taking care of this individual.
    I think we need to do a better job of coordinating care. I 
think there is a woman in the audience, now, and she is part of 
our group, as well, and I always remember, her husband was 
diagnosed with the disease. She would walk out of the 
provider's office and say, what do I do now? I often refer to 
it as opening Pandora's box, and, there was not the coordinated 
care she needed for her to figure out how do you go along and 
make sure that she manages the disease successfully. She 
actually stumbled around for several months before she went to 
the Alzheimer's Association.
    Finally, I think that we need to monitor the caregivers' 
health. We need to make sure that we provide them respite and 
resources for that, because it takes a heavy toll on them 
physically and mentally. We need to monitor them for 
depression, and, we need to relieve some of the financial 
burden on the family, as well.
    Senator Walsh. Dr. Finke.
    Dr. Finke. I will answer that, that there is a small but 
important body that is around specific interventions that 
improve caregiver health. Some of this work comes out of the 
REACH research from the--funded by the National Institutes of 
Aging. REACH stands for Resources for Enhancing Alzheimer's 
Caregiver Health, and, this work demonstrated an intervention 
that actually did improve outcomes for both caregivers and 
persons with dementia. The VA has taken that work, adapted it 
for the VA, evaluated it, and is now spreading it across the 
system as the REACH VA program, a highly successful program 
within the VA.
    As I mentioned briefly earlier, the IHS is working with the 
Administration on Aging within the Administration for Community 
Living with the VA to take that model and bring it into Indian 
County. I think there has also been work through the 
Administration on Aging outside of Indian Country to adapt that 
model, but that is--I think we are really excited about this as 
a structured way to support caregivers as part of the 
caregiver--as part of caring for the individual with dementia.
    Dr. Carlson. One thing, I think, that cannot be 
overemphasized is the importance of diagnosis, early diagnosis 
as soon as practical, allowing the patient to plan and the 
caregivers, before they actually are caregivers, to know what 
resources are available. That is what we are trying to 
implement with Benefis Health System.
    A telling study was done by Riley McCarten in Minneapolis. 
He took 8,000 veterans 70 years of age and older who had no 
record of any cognitive impairment in their records. They were 
seeing the physicians for other reasons. He implemented, or 
tested each one of these, and with a very simple cognitive 
test--it takes two or three minutes--27 percent of those 
failed, and on followup, 95 percent of those who failed were 
shown to have clinical dementia, so, if those people were 
identified earlier on, there would be less people not bringing 
their parents or their wife or husband in a moment of crisis, 
but having time to find the resources and to get help when they 
most need it.
    Senator Walsh. Dr. Carlson, are these tests available from 
your local physician, or how would you----
    Dr. Carlson. What we are trying to do now with Benefis, and 
this has been implemented in Minneapolis, is the test is 
actually--it is called a mini-cog. You are just asked to 
remember three words over a, it is, like, a two-or three-minute 
period and draw a clock with a particular time on it, so, it 
would be like the vital sign. When the nurse takes your 
temperature and height and weight and your blood pressure, they 
would administer this simple test before you go and see the 
physician, and then the physician would be the one responsible 
to followup, if necessary.
    Senator Walsh. Okay. Great. Thank you.
    The next question is from Janice. It is for Dr. Carlson. 
Has the McLaughlin Institute applied for funding from the 
National Active and Retired Federal Employees through the 
National Alzheimer's Association? And, then, where else have 
you applied for and received funding?
    Dr. Carlson. The bulk of our funding has come from the 
National Institutes of Health, and I was not aware of this 
funding source, so thank you very much, if funding is available 
through that, but, most of it is through the Federal 
Government, both National Institute on Aging and National 
Institute for Neurologic Disorders and Stroke. We also have 
applied for--the Alzheimer's Association gives grants, as well.
    One thing I would like to emphasize is the success rate now 
is terrible. As recently as seven or eight years ago--the way 
the grant applications work at the National Institutes of 
Health is it goes to a panel of scientists for peer review. The 
applications are ranked and given a percentile score, so, it 
has always been competitive, which is a good thing, but they 
would fund between 15 and 20 percent of these basic research 
applications. The top 15 or 20 percent were very likely to 
receive funding.
    With the National Institute of Aging now, the cutoff has 
been as low as six or seven percent, and I do not think the 
peer review system has the resolution to tell--to say that an 
application that scores in the top six percent is significantly 
different from that which scores in the top ten percent or 
fifteen percent, and that is where increased funding could 
really make a difference, in getting realistic--going back to a 
realistic competition rather than this hyper-competitive 
situation we are in now.
    Senator Walsh. What country would you say has taken the 
lead role on research, as far as investment and moving forward?
    Dr. Carlson. Well, as a percent of GDP, places like Israel, 
Great Britain, but, still, and this is why it is worrying, the 
U.S. still has the best research in the world, but, other 
countries, the rate of increase in China and India is 
frightening, but, we are still--you know, with our university 
system and our funding for the National Institutes of Health, 
even though it is going down, we are still at the top, but, it 
is not a God-given right to be at the top and I think we have 
to work on it and have increased funding for research.
    Senator Walsh. Okay. Ms. Burke, this question is for you. 
What would your advice be for someone who has recently been 
diagnosed with Alzheimer's as their first stop to find 
information or support services, especially for someone from a 
rural part of our State?
    Ms. Burke. I think the Alzheimer's Association. We have a 
fantastic Montana branch. We also have a national one. The 
glitch that we have discovered in our Work Group is that access 
to information is difficult in our rural area. They have 
fantastic websites, but if the Internet is not working well, 
that is a problem, but, I think, they could contact the office 
here in Billings. There are also additional websites, and, like 
I said, I wrote down some of the ones that I have used, and the 
government now has one, Alzheimers.gov.
    I think the education is important. If we can help each 
other figure that out via the website, you can take that 
information and talk to your local care provider. You could 
probably make arrangements to make a long trip to Billings, 
depending on where you live in the State, to come here, but, 
education is so important, and the support of people who have 
been dedicating their organizations and lives to this disease 
to help for education is something that needs to be tapped 
into.
    Sometimes, knowing about resources is a difficult thing, 
and I think the Alliance does a really good job of that. They 
have a book called, Whom Do I Ask?, and it is not just about 
Alzheimer's, but it is all kinds of resources that are 
available in the Billings community. Again, that might not be 
as helpful for the geographically isolated parts in our State, 
but it is a place to start, because they are always willing to 
share the knowledge, and that is what needs to be done, in my 
mind.
    Senator Walsh. Okay, great. This question is from Marcia 
and it is for me, and the question is, what will the Ryan 
budget do to Alzheimer's?
    My answer there is that the House passed Congressman Ryan's 
budget in April. It does not specifically cut Alzheimer's 
research at the National Institutes of Health, but it proposes 
an almost $800 billion to be cut over the next decade from the 
non-defense/discretionary budget, so, realistically, that would 
cut NIH funding by as much as one-third by 2024, so, that is 
something I am not supportive of. I think that, you know, based 
on what we have heard here today, we need to continue to invest 
and put additional resources into research.
    With the McLaughlin Institute, and when I was serving as 
the Lieutenant Governor, along with Governor Bullock, we 
visited the McLaughlin Institute to see what they were doing, 
and we looked at it like the--you know, not only from the 
United States perspective, but Montana, having this resource 
right here in the State of Montana, we could become a leader in 
the United States with the resource that we have right here in 
our backyard in Great Falls, Montana.
    I know that--and, that is one of the reasons Governor 
Bullock initially invested in, or put some money into research. 
I am confident that he will continue to invest in this area, 
because with Montana's--you know, our population is aging and 
we need to invest in this area, but not only from the State of 
Montana, but we could become a leader nationwide where other 
States are coming to Montana to find out what we can do--what 
they can do to better prepare for this terrible disease.
    The next question, again, is from Elaine for Dr. Carlson. 
Please discuss family DNA and Alzheimer's. I am sorry. That 
one, we already had.
    This is the next question. Again, it is for me. What can be 
done to invest in research, and how can we prioritize help for 
families?
    My answer is that there is clearly more that we can do. I 
think we have heard from all of our panelists that education is 
very important. Early identification is important, and, 
communication is extremely important, but, two things that we 
can do. You know, there are two bills that we should pass 
immediately. The first one is the Alzheimer's Accountability 
Act, which would require an annual budget for the NIH for 
Alzheimer's research to meet the goal of preventing and 
treating Alzheimer's by 2025, and, then, we should also pass 
the HOPE Act, which will open more Medicare services for 
Alzheimer's treatment, so, those are two things that I think 
that we can do immediately to take on--to take steps forward.
    This next question is for Dr. Carlson. Again, Dr. Carlson, 
I want to thank you for the great work that you do at the 
McLaughlin Institute. Your testimony did a great job of showing 
that Federal funding for Alzheimer's research may not be 
enough, given the tremendous challenges that this disease 
presents for our country, but, the question is, what are some 
of the opportunities for further scientific research that are 
not being taken advantage of now, but would be taken if 
Congress increased investment in Alzheimer's research?
    Dr. Carlson. That is a very good question, and what happens 
when the funding gets tight--this is not unique to the National 
Institutes of Health, but just in general, if there is a 
limited amount of funds, people become more conservative in 
distributing those funds, so, the more innovative ideas are the 
ones that suffer, so, the grants that are funded are ones that 
are on paths that seem to be promising, even though those paths 
have not proven to be successful, so, someone who proposes 
something entirely new and entirely different and does not have 
preliminary results to support it, they are not going to get 
funding.
    Basically, it is trying to identify the more innovative, 
new approaches to research that have not been tried before, and 
if there is enough money, you can fund those things rather than 
the same stuff that has yielded good results, but it has not 
yielded any preventative treatments or cures just yet.
    Senator Walsh. Okay. Thank you.
    Finally, the last question that I have is for Dr. Coon. You 
know, we are looking forward to seeing the ultimate work of the 
Montana Alzheimer's/Dementia Work Group. Please do not hesitate 
to reach out to my office if there is anything we can do to 
help. We want to be helpful. Although you still have work to 
do, what are your initial thoughts about unique approaches that 
would be particularly effective in a rural State like Montana?
    Dr. Coon. You know, I think that what--as we, as a Work 
Group, speak, what we really are talking about, how do we 
improve coordinated care within not only the State, but in the 
community, in general, so, it is really looking at community 
efforts to coordinate care, bring like resources available to 
those individuals in the community, and that is, I think, the 
main challenge we are going to have.
    There are models of care out there that currently could be 
implemented, but we are talking about a community at a State 
level. Some of that--and I am going to make a plea for another 
research bucket--so, there also needs to be dollars put toward 
health services research that allows us to take these models, 
implement them in communities to see if we can improve the 
outcomes of these individuals by truly providing coordinated 
services throughout those facilities. Higher education, better 
education with these individuals, having those resources 
available to the families, that all needs to take place at a 
community level and not necessarily at a State, at a Federal 
level, so, I think, that is the direction where we are really 
going for the Work Group at this time.
    Senator Walsh. Okay, great.
    I do have one more question, and that is for Dr. Finke. 
Again, I want to thank you for coming to Montana to share your 
experience. Alzheimer's is a disease that affects everyone, no 
matter who you are or where you live. Can you go into a little 
further detail about the Indian Health Service outreach to 
Reservations about Alzheimer's, and what should Montana Tribes 
expect to see from IHS in the coming years?
    Dr. Finke. Thank you. The Indian Health Service is a 
primary care-based health system, as you know, and so our work 
around the Alzheimer's and dementia on the clinical basis 
really is going to be about building the structures and the 
platform of care in the primary care level to be able to 
provide the kind of coordinated managed care that individuals 
with Alzheimer's and their families need.
    I mentioned in my initial comments the Improving Patient 
Care Program, which is the medical home model, and I think what 
we see out of the medical home model is a more robust platform 
of primary care. We see this already at Northern Cheyenne, for 
example, where they have been working on this model longer than 
others and they have begun--they have care teams building 
continuity of care with panels of patients, and those teams are 
actually doing outreach and care management for elders, for 
frail elders and elders with dementia, out of their care teams, 
and, I think, building a more robust, capable platform of 
primary care will help us to manage--support and manage care 
for folks with Alzheimer's and their families.
    I also think we should expect to see, as we work with the 
VA, with the Administration on Aging around the REACH 
intervention, more structured support for family caregivers 
and, really, an approach that says, care for a person with 
Alzheimer's involves care for those who care for them, as well.
    Senator Walsh. Okay, thank you.
    Just a real quick survey. Just a show of hands of how many 
in our audience today have been impacted in one way or another 
by Alzheimer's.
    [Show of hands.] Wow. When you look at just our audience 
here today and our State, sooner or later, we probably will 
all, in some way or another, be affected, so, whatever we can 
do to provide additional resources for research to combat this 
problem, it is something that we should do, and, I can promise 
you that I will work very hard in the U.S. Senate for the time 
that I will be there to fight for additional resources, because 
this is a very debilitating disease that affects so many of us 
in the State of Montana and around the country.
    Again, I want to thank all of the panelists who came today 
with your testimony. We will make sure that--as a member of the 
Aging Committee, I will take this information back to 
Washington, D.C., and share it with my colleagues on the Aging 
Committee, so, thank you very much for being here.
    I want to thank all of the--everybody who attended today 
for showing up just because of your interest in this. I am 
confident that we will move forward and progress in fighting 
this terrible disease.
    Then, finally, I would like to--you know, when we put 
committee hearings and meetings like this together, I get to 
sit up here in front and take a lot of the credit for doing 
this, but I can tell you that it does not happen without a lot 
of work from a lot of people behind the scenes, and, 
especially, I would like to have Jim Corson and Matt Peterson 
to please stand up and take a round of applause.
    These gentlemen are members of my staff here in Billings 
and they do a tremendous amount of work, and so if there are 
other issues or input that you want to have for our staff that 
you want us to receive in Washington, D.C., please do not 
hesitate to reach out to them.
    Again, thank all of you for being here. I think that we 
have some refreshments and cookies in the back, and, again, 
thank you so much to our host facility--yes.
    Ms. Gibson. Senator, I am Heidi Gibson from the Alzheimer's 
Association, the Montana Chapter. I would just like to 
cordially invite you to the Walk to End Alzheimer's in Billings 
September 21st at the zoo. There is information on the back 
table, not only about the walk, but just about connections, 
caregiving, and we are really better together, but also bills 
that the Senator mentioned, the HOPE Act and also the 
Alzheimer's Accountability Act.
    Senator Walsh. Thank you, Heidi.
    Any other comments?
    [No response.] Okay. Again, thank you all, and enjoy the 
rest of your day.
    [Whereupon, at 11:06 a.m., the Committee was adjourned.]

   
      
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                                APPENDIX

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                      Prepared Witness Statements

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                       Statements for the Record

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