1. “Whealthcare” for Banking and Insurance Jason Karlawish, MD University of Pennsylvania Departments of Medicine, Medical Ethics & Health Policy, and Neurology Healthy Brain Research Center Penn Neurodegenerative Disease Ethics & Policy Program

3. Key points about the Aging Brain The passage of time is associated with changes in cognition…. – diseases that impair cognition: neurons die – age-related cognitive changes: neurons don’t work as well Changes in cognition can lead to changes in abilities to perform tasks and make decisions Managing money is one of the first abilities (activities of daily living) that is impaired

4. Consequence The banking & financial services industries are on the front lines of screening and detection So what are we going to do about that…

5. Crystallized vs Fluid Abilities fluid abilities active processing of new information, (such as learning a new game) in novel situations, thinking logically & solving problems important to new learning and skill acquisition NAM/IOM. Cognitive Aging. 2015

6. Comparison GroupAlzheimer’s Group...With some help (0) Completely able Months Mean Scores Group: NS Time: F=6.54, p<.001 Time x Group: NS Group: F=18.1, p<.0001 Time: F=29.4, p<.0001 Time x Group: F=9.78, p<.0001 Linear Trend: F=19.35. P<.0001 Cubic Trend: F=7.39, p<.01 ++++ Kiyak, HA. Teri, L. Borson, S. Physical and functional health assessment in normal aging and in Alzheimer’s disease: self-reports vs family reports. Gerontologist. 34(3):324-30, 1994.

7. Summing Up Over time –knowledge grows –thinking fast and multitasking declines –emotional regulation improves –time perspective shortens –as a persons develops cognitive impairments, she tends to underestimate their impact on function These changes aren’t uniform –quite variable

8. Performing financial tasks Gambler et al. How does aging affect financial decisionmaking? Center for Retirement Research Issue Brief. January 2015.

9. Performing financial tasks Agarwal at al. What is the age of reason? Center for Retirement Research. 2010.

10. Every Day Cognition: Computer use changes over time in Mild Cognitive Impairment At Baseline: Mean 1.5 hours on computer/per day Over time: –Less use days per month –Less use time when in session –More variable in use pattern over time IntactMCI Kaye, et al. Alzheimers Dement. 2014; Silbert et al. JAD, 2016

11. Performing financial tasks Older adults and banks suffer from what happens to their brains –Older Americans lose at least $3 billion per year because of financial exploitation –Average victim loses $120,000 –Banks lose $1 billion a year from exploitation AARP’s BankSafe Initiative. 2016.

12. This is a public health issue Many factors lead to the problem –Changes in the brain –Cardiovascular health, physical exercise –Medications and hospitalization –Social and economic exposures –Family size, structure and location –Banking and financial service practices –Regulatory structures The U.S. has a national Alzheimers plan –Goal #1: prevent it by 2025

13. This is a public health issue The issue affects others –average victim loses $120,000—almost the average amount a 50+ household has in retirement savings –banks lose $1 billion a year Money lost in later years is hard to earn back & it is needed acutely Organized public/private efforts can address it

14. You need a business model… Fuse wealth care with health care –You need to start practicing whealthcare

15. The Social Ecological Model

16. Putting whealthcare into practice Change the language –from “stopping elder abuse, fraud and exploitation” to “assuring financial well-being through whealthcare”

17. Putting whealthcare into practice Deploy technology –biometric debit/cash cards –third party read-only accounts –monitor the aggregated data to surveille for problems –learning algorithms to predict who may have problems

18. Motion Detectors Contact/Door Switches Phone Sensors Load Cells / Bed Sensors Sleep Medication Tracker Computer Raw Sensor Data Weight Scale Phone Use Computer Interactions Gait Velocity Weight Medication Events Departures Arrivals Location Estimation Location Traction Mobility Sleep Hygiene Socialization Medication Adherence Depression Physical Impairments Memory Attention Direct Assessment Sensor Fusion Info Fusion InferenceFrameworks ADLs IADLs EADLs Frailty Chronic disease management Independence Quality of life

19. Motion Detectors Contact/Door Switches Phone Sensors Load Cells / Bed Sensors Sleep Medication Tracker Computer Raw Sensor Data Weight Scale Phone Use Computer Interactions Gait Velocity Weight Medication Events Departures Arrivals Location Estimation Location Traction Mobility Sleep Hygiene Socialization Medication Adherence Depression Physical Impairments Memory Attention Direct Assessment Sensor Fusion Info Fusion InferenceFrameworks ADLs IADLs EADLs Frailty Chronic disease management Independence Quality of life Interventions Clinical Decision Support Cognitive support Care Coordination Social support Rehabilitation

20. Putting whealthcare into practice Change your business practice –engage clients with a model of shared decision-making lots of studies of this in medical decisionmaking –what should you ask a client in order to understand her as an individual (no measurement, no science; no science, no good reason to act)?

21. Putting whealthcare into practice Change the rules and regulations –rules and regulations for reporting suspicious activity, holds on transactions, transactional obligations to clients (carrots & sticks)

22. A snapshot from “Snapshots” AARP. BankSafe. 2016

23. A snapshot from “Snapshots” AARP. BankSafe. 2016

24. Selected references The National Academies. Cognitive Aging: Progress in Understanding and Opportunities for Action. 2015. –Chapter 2. “Characterizing and assessing cognitive aging” –Chapter 6. “Financial decisionmaking” President’s Council of Advisors on Science and Technology. Independence, Technology, and Connection in Older Age. 2016. –Chapter 3. “Technologies to address changes in cognitive abilities.” NCRC. “A New Dawn: Age Friendly Banking.” 2013 AARP. “Snapshots: Banks Empowering Customers and Fighting Exploitation.” 2016

25. Thank you Jason Karlawish, MD www.jasonkarlawish.com Jasonkarlawish@gmail.com @jasonkarlawish