Protecting Elders and the Impaired From Sexual Abuse

How do we protect elders and the impaired, or more personal, our family members, from sexual abuse? We interview caregivers and review references for someone to provide assistance while we are working or we trust an assisted living facility to care for our loved ones. Concurrently, we worry about vulnerability and find the progression to our own future frail, vulnerable state to be terrifying and depressing. 

Elder sexual abuse is under reported and under diagnosed. It is difficult to detect in many cases because the victim cannot articulate or clearly remember what happened. One strategy, however,  in the detection of elder sexual abuse is to identify at-risk elders and concentrate efforts with this population. 

Social isolation of the elder may account for a barrier in detecting sexual abuse. But even the most isolated elder will visit a health care provider at some point which on average is about five times a year. Nevertheless, health care providers percentages of reported abuse cases is small-about 20% or less. 

For a frail, dependent elder, the primary care provider may be the only opportunity for abuse detection and yet, many primary care givers believe the symptoms are related to aging and disease rather than abuse. Researchers analyzed a set of State of Michigan records of reported cases of elder abuse for the years 1989-1993 and noted that physicians reported an average of only 2% of all cases reported. It was suggested that increasing physicians and nurses awareness of the problem of elder sexual abuse could increase the number of cases screened for potential abuse and as such increase the number of elder sexual abuse reports to responsible agencies.

All suspected cases of elder sexual abuse should to be reported for two reasons. The first reason is to provide for the safety and protection of the elder and the second reason is to prevent further victimization by the perpetrator. Cases need a rapid and immediate report to those in charge of their care, to the physician (if an institution case) and a complete physical examination by a qualified sexual assault forensic examiner. The absence of such reporting and documentation in a nursing home places the facility at risk for negligent protocol. 

Within the care providing role, observations of the vulnerable elder are very important in verifying on going abuse. Although specific evidence may be difficult, home care providers can increase their visits and observations as a strategy to increase the body of evidence.There is a reporting hesitance  in family cases of elder abuse. Elder abuse laws are designed and intended to protect vulnerable citizens and to punish violators. But people are concerned about and investigations and repercussion if they are wrong. 

Barriers identified to detecting elder abuse include: families/patients resistance to intervention once elder abuse is identified, families/patients denial of abuse, fear of reprisal by the abuser towards the elder, lack of professional protocols for responding to elder abuse, lack of clear guidelines about confidentiality in elder abuse situations, difficulty in determining what constitutes elder abuse, and the lack of knowledge about the prevalence of elder abuse. 

Recommendations include an elder abuse package for education, detection and management  of elder abuse with a website as well as professional guidelines for detection and management.

How do we identify when sexual abuse may have occurred versus the normal personality changes when the person has dementia or Alzheimers? It’s the focus of the next blog.

Sources:  “Elderly Victims of Sexual Abuse and Their Offenders”, Ann W. Burgess, U.S. Department of Justice, December 2006.  “Elder Abuse,”  National Institutes of Health.

 

 

 

You Can’t Donate Blood. You May Have Malaria!

I was not allowed to donate blood yesterday because I might have malaria. It was one of those days when everything was a bit off center. I was driving back from the airport where I drove my two elderly and physically impaired relatives for a one hour flight. It required airport arrival no later than 2.5 hours in advance so they wouldn’t miss the flight …  Driving home, I spotted a sign for a blood drive but the shock came when I was denied donating because I recently returned from a vacation in Greece where there had been some malaria outbreaks in rural areas. I am banned from donating blood for a year.

 Malaria occurs in nearly 100 countries worldwide and affects more than 200 million people. About 655,000 people died from malaria in 2010, more than 90 percent of them in sub- Sahara Africa. Major gains have been made in controlling malaria in developing nations. In the past decade, malaria incidence has fallen by at least 50 percent in one-third of the countries where the disease is endemic. These gains have been made through a combination of interventions, including timely diagnosis and treatment using reliable tests and anti-malarial drugs; indoor spraying with safe insecticides; and the use of long-lasting, insecticide-treated bed nets to protect people from mosquito bites at night. The Bill and Melinda Gates Foundation have targeted the disease and made a tremendous contribution in the eradication even employing Tanzanians to sew with gloves insecticide sprayed netting for over beds.

Malaria is preventable and treatable, and it can be eliminated. Less than a century ago, it was prevalent across the world. In high-income countries, aggressive prevention measures and more effective monitoring and treatment gradually brought the disease under control and then led to elimination—which the World Health Organization defines as the complete interruption of mosquito transmission of the disease for three or more years. The United States eliminated it in 1951.  The challenge globally is eradication when parasites develop resistance and provide new threats. Fortunately, malaria funding has increased almost six-fold since 2003. Through the Global Malaria Action Plan, the World Health Organization (WHO) and the Roll Back Malaria Partnership are coordinating international efforts.

Malaria in the United States

• On average, 1,500 cases of malaria are reported every  year in the United States, even though malaria has been eliminated from this country since the early 1950’s.
• First- and second-generation immigrants from malaria-endemic countries returning to their “home” countries to visit friends and relatives tend not to use appropriate malaria prevention measures and thus are more likely to become infected with malaria.
• Between 1957 and 2011, in the United States, 63 outbreaks of locally transmitted mosquito-borne malaria have occurred; in such outbreaks, local mosquitoes become infected by biting persons carrying malaria parasites (acquired in endemic areas) and then transmit malaria to local residents.
• During 1963-2011, 97 cases of transfusion-transmitted malaria were reported in the United States; approximately two thirds of these cases could have been prevented if the implicated donors had been deferred according to established guidelines.

Every year, millions of US residents travel to countries where malaria is present. About 1,500 cases of malaria are diagnosed in the United States annually, mostly in returned travelers but sometimes from flights when a pesky parasite is released into the airport. Travelers to sub-Saharan Africa have the greatest risk of both getting malaria and dying from their infection. However, all travelers to countries where malaria is present may be at risk for infection.

The Malaria Information by Country Table provides detailed information about the specific parts of countries where malaria transmission does or does not occur. It also provides additional information including the species of malaria that occur there, the presence of drug resistance, and the specific medicines that the CDC recommends for use for malaria prevention in each country where malaria transmission occurs.

So now you summer travelers have the update on malaria. BTW, I was feeling chilled but now I am dripping hot-is it malaria or the margarita and salsa covered nachos?

Sources: Center for Disease Control, cdc.gov.malaria/travels/countrytable/, Global Health-Division of Parasitic Diseases & Malaria.

Aging with Alzheimer’s Disease

One of the fears of aging is how do I maintain dignity and control over my dying if I have Alzheimer’s Disease? The amyloid plaque deposits in the brain start around 17 years before mild cognitive impairment and then rises dramatically over ten years before the onset of impairment. Nearly half of people living to 85 are at risk compared to only 10% at 65. Recent estimates indicate that the 5 million people with Alzheimers today will triple to 13.8 million Americans by 2050. What about the long term costs for care? Can I afford better care with my savings-for how long?

I recently read the award winning New York Times best seller Still Alice., by Lisa Genova. It describes the life of a fifty year old Harvard Professor, Alice, with an equally accomplished spouse and three grown children who is diagnosed with Alzheimer’s Disease. It artfully depicts the stress on the family and the limiting of options for them as they become caregivers as well as their own fears for their future and that of their children. The disease changes the professor’s life and her relationship with her family but a new way of living and loving evolves as does the care needs.

A third of current caregivers have been providing care for more than five years and 10% for more than ten years. Recent research indicates that caregivers using a problem focused care strategy produced better outcomes for themselves and their loved one than emotion based which includes avoidance or guilt. What about the human costs for caring for the loved one with dementia?
There are no exact answers to the questions or regarding financial impact. But as we age, we need to face our eventual body and mind declining and put together the legal documents of what we want to occur as our health wanes. We need to put the end of life legal documents in place while our brain is functional, appoint a legal surrogate as the decision maker, and make informing our family members of our wishes a top priority.

For some people, the thought of slowly dying from Alzheimer’s Disease is not desirable and they choose to voluntarily stop eating and drinking while still mentally competent rather than a slow progression resulting in the same end. The process can take one to two weeks. It is controversial and sometimes unsupported by family members and medical providers. People interested in learning more about this option may contact Compassion & Choices, http://www.compassionandchoices.org, the Alzheimer’s Association, http://www.alz.org, or the National Association of Elder Law Attorneys, http://goo.gl/QbZ7m. In any case, it is important that you define your end-of-life wishes. If you are diagnosed with Alzheimer’s disease, you must execute the documents while still mentally competent.

Sources: Älzheimer’s and end-of-life decision making,” by Robb Miller, Aging Today, May-June 2013. “Alzheimer’s, the age boom and the search for a cure”, by Gary Small, Aging Today, May-June 2013.

Aging Is Not For Sissies But You’re Happier

Feeling muscle and joint pain? Can’t sleep and waking up multiple times and rushing to the bathroom? The good news is that aging is very slow; and sometimes not visible from one year to the next. The natural aging process is a relatively minor process until you’re about 90. According to Larry Matson, Ed.D., coauthor with Donald M. Vickery, M.D., of Live Young, Think Young, Be Young … at Any Age.
Fifty-one percent of Americans think they actually look younger than their age. Staying mentally and physically active can help keep you younger. Everyone ages differently, and lifestyle plays a major role, but you’ll still experience both hard-to-notice and impossible-to-miss changes in your physical and mental health.
The likelihood of getting an outbreak of acne is greatly reduced as we age. That’s because your skin is getting drier, making blemishes less common. The not so good news with age is the loss of muscle, bone and fat under the skin and changes in collagen and elastin that makes fine lines and wrinkles more pronounced especially if you are a smoker or sunned a lot. One thing that can help is prescription retinol products like Retin-A or Renova, says Helen M. Torok, M.D., medical director for the Dermatology & Surgery Center at Trillium Creek in Medina, Ohio. These creams repair damaged skin by speeding cell turnover. Choose skin products with antioxidants and glycolic acid, which promote skin thickening and increase collagen production. The 50s is when increased age spots and skin tags begin. A dermatologist can prescribe a dydroquinone product for the age spots and can remove the skin tags.
Particularly in your 60s, you may develop dilated superficial blood vessels on the cheeks, nose, chin and legs. Doctors can zap them with a laser that destroys the blood vessels underneath the skin without leaving a scar. Other options to help make skin look younger: radio-frequency-emitting devices that tighten the skin, and plasma skin resurfacing. Also, Botox and injectable fillers like Radiesse, Restylane and Juvéderm can reduce wrinkles. Your senses of taste, smell and touch remain mostly intact.
You’ll probably start needing reading glasses. As you age, the lenses in your eyes stiffen, making it harder to focus up close. You may become sensitive to glare, and your night vision may decrease, as those same lenses begin to lose clarity. Plus, dry eye becomes more common, says William B. Trattler, M.D., an ophthalmologist at the Center for Excellence in Eye Care in Miami, Florida. Medications like Restasis can help, as can omega-3 fatty acids, found in fish like salmon. In general, 60-year-olds need three times as much light to read as 20-year-olds. And after age 60, the risk of macular degeneration increases. Hearing loss becomes more common in your 60s, due to the effects of a noisy environment.
The metabolism usually slows up to 5 percent per decade so you need to “eat less and move more”. Eat more whole grains, fruits and vegetables, low-fat dairy products and fish, says Alice Lichtenstein, D.Sc., director of the Cardiovascular Nutrition Laboratory at the USDA Human Nutrition Research Center on Aging. Unfortunately, your stomach empties more slowly, which can increase the risk of reflux. And the slowing of digested material through the large intestine can trigger constipation so eat more fiber, says John I. Hughes, M.D., a gastroenterologist with the Kelsey-Seybold Clinic in Houston.
If you’ve been active all your life, your bones, joints and muscles have a better chance of being in pretty good shape during your 50s and beyond. Aging and inactivity can lead to achy joints because of the wearing down of cartilage, the loss of lubricating joint fluid and weaker muscles. Some remedies: maintaining a normal weight and strength training. An estimated one in five women 65 to 74 has osteoporosis.
Many people in their 50s will start to develop the first signs of heart disease. Thanks to new treatments and the mitigation of risk factors like high cholesterol, the death rate from heart disease declined 27.8 percent from 1997 to 2007. Nevertheless, heart disease is the leading cause of death for people 65 or older, so try exercising to reduce the risk and eat the “Mediterranean” diet.
The good news about aging is that over 70% of men and women say their sex lives are better after 40 because you aren’t working, raising children, keeping the activities and home together and exhausted at days end-plus no one is pounding on the door asking what’s for dinner. Smoking and a sedentary lifestyle have a negative impact on sex.
The really terrific news is that we get happier as we age with those in their 70’s pretty consistently happy and satisfied. “As you get older, you know that bad times are going to pass,” says Laura Carstensen, Ph.D., director of the Stanford Center on Longevity. “You also know that good times will pass, which makes those good times even more precious.”

Sources: Besides stated references, some excerpts from AARP Magazine. Photo from Creative Commons Cecilia Moller.

Value of the Family Caregiver

Family care giving includes all unpaid services provided by family and friends. Because of gaps in the healthcare system and family preferences, family and friends are providing most of the care for those with chronic conditions. Meanwhile, the afflicted not only are in physical discomfort but also have major concerns that they will become an economic and emotional burden. Depending on the assets of the elder or impaired and the state of residence, the caregiver may receive monetary assistance from Medicaid.

To better understand the value of care giving, in 1997 home health care was $32 billion, nursing home care was $83 billion, and the value and savings for the health care system as a result of family care giving was $196 billion.[1] 

Forth-three percent of those providing care are 50 years or older and sixty-one percent of family care givers are women.  Forty per cent of family caregivers are employed full time, have families, and spend 20 hours a week being a caregiver frequently for parents.[2] For caregivers who provide 40 hours or more per week, 29% tend to be in fair or poor health, with 28% aged 65 or older.[3]  One research study found that elderly people who felt stressed while taking care of their disabled spouses were 63 percent more likely to die within 4 years than caregivers who were not feeling stressed.  Caregivers frequently do not get enough sleep, get enough physical activity, or eat enough healthy meals due to depression and/or time constraints.  While caring for a family member can be a wonderful, rewarding experience, you have to find resources to provide some balance and personal time to retain your mental and physical health.

Ask your doctor or call the Area Agency on Aging for information on classes and support resources for the caregiver. It can mean the difference in maintaining you health or life itself.

---

[1] Arno, PS, Levine, C and Memmott, MM, “The Economic Value of Informal Caregiving,” Health Affairs, 18:2, March/April 1999.

[2] Caregiving in the U.S., National Alliance for Caregiving and AARP, 2004.

[3] Alecxih, LMB, Zeruld, S and Olearczyk, B. ‘Characteristics of Caregivers Based on Survey of Income and Program participation.” National Family Caregiver Support Program. Administration on Aging, Lewin Group, 2001.

Sleep Disorder Symptoms and Iron Deficiency

We frequently discuss sleep disorder symptoms involving the inability to sleep but what about people who experience overwhelming chronic fatigue?

Iron is a mineral needed by our bodies. Iron is a part of all cells and does many things in our bodies. Iron (as part of the protein hemoglobin) carries oxygen from our lungs throughout our bodies. Having too little hemoglobin is called anemia. Iron also helps our muscles store and use oxygen.

Iron is a part of many enzymes and is used in many cell functions. Enzymes help our bodies digest foods and also help with many other important reactions that occur within our bodies. When our bodies don’t have enough iron, many parts of our bodies are affected. Iron deficiency is a condition resulting from too little iron in the body. Iron deficiency is the most common nutritional deficiency and the leading cause of anemia in the United States. The terms anemia, iron deficiency, and iron deficiency anemia often are used interchangeably but equivalent. Iron deficiency can be the cause for fatigue which impacts the ability to do physical work as well as affecting memory.

What causes iron deficiency?

Iron deficiency has many causes.  Pregnant women or people that lose blood have an increased iron need. People may have decreased iron absorption caused by many factors including diet:

• Iron from meat, poultry, and fish is absorbed two to three times more efficiently than iron from plants .
• The amount of iron absorbed from plant foods depends on the other types of foods eaten at the same meal.
• Foods containing heme iron (meat, poultry, and fish) enhance iron absorption from foods that contain iron (e.g., fortified cereals, some beans, and spinach).
• Foods containing vitamin C enhance iron absorption when eaten at the same meal.
• Substances (such as polyphenols, phytates, or calcium) that are part of some foods or drinks such as tea, coffee, whole grains, legumes and milk or dairy products can decrease the amount of non-heme iron absorbed at a meal. Calcium can also decrease the amount of iron absorbed at a meal.
• Vegetarian diets are sometimes low in iron, but careful meal planning can help increase the amount of iron absorbed.

What can I do to prevent iron deficiency?

You can eat a healthful diet that includes good sources of iron. A healthful diet includes fruits, vegetables, whole grains, fat free or nonfat milk and milk products, lean meats, fish, dry beans, eggs, nuts, and is low in saturated fat, trans fats, cholesterol, salt, and added sugars.

• In addition to a healthful diet that includes good sources of iron, you can also eat foods that help your body absorb iron better. For example, you can eat a fruit or vegetable that is a good source of vitamin C, it helps your body better absorb iron.
• Eat red meats, poultry, and fish. The iron in these foods is easier for your body to absorb than the iron in plant foods.
• Fortified cereals, navy beans, soybeans, pumpkin, white beans, lentils, spinach, chickpeas, molasses, lima beans, and tomato puree.

How much iron do I need?

If you have already been diagnosed with iron deficiency, talk to your doctor or healthcare provider about treatment. For healthy individuals, the Recommended Dietary Allowance (RDA) for Males aged 19 and older for iron is 8mg/day and for women aged 19-50 is 18mg/day and over 50 it is 8mg/day.

If you are feeling the sleep disorder symptoms of chronic fatigue, schedule an appointment with your doctor. A diet change may be all you need to return to healthy sleep patterns.

The article sources are:
Center for Disease Control adapted from: Recommendations to Prevent and Control Iron Deficiency in the United States. MMWR 1998;47 (No. RR-3) p. 5 and Dietary Reference Intakes, Institute of Medicine, Food and Nutrition Board.

 

 

 

Surviving Breast Cancer

I am posting an inspirational article that provides hope for the many women and some men who are diagnosed with breast cancer. While the treatment has evolved significantly, the “C” word is terrifying especially when you have a young family. So here is a “feel good” story!

Posted: Aug 09, 2012 3:16 PM

By Rachel Schaerr

Amherst Co., VA – Two years ago, doctors diagnosed an Amherst County woman with breast cancer. Pretty soon, people all over the country are going to read about her story.

Deb Belous grew up wanting to be a writer. Now, one cancer fight and several years later, she’s finally going to get that chance.

In September of 2010, breast cancer’s was just beginning.

“I was so afraid of not seeing her grow up, of her not having a mom,” said Deb Belous.

Belous didn’t know how long she’d live.

“The physician’s assistant, who worked with the surgeon, grabbed me by the shoulder and she looked me in the eyes and she said ‘You are going to beat this,'” she said.

Words became Deb’s therapy, and she began writing about her body.

“When 90 percent of my hair fell out and I was left with a few straggling strands, Rick told me I was still beautiful,” she said reading from her journal.

Her blood-queasy husband transformed too.

“Rick changed from someone who turned green at the thought of watching an ER episode to someone who bravely performed wound care,” she continued to read.

Eventually, the page turned on Deb’s cancer. After 12 months of fighting and seven weeks of radiation, she rang the gong on her final day of treatment.

“It was a very strange feeling like, ‘What’s next? What am I supposed to do? What are my days supposed to be filled with?'” she said.

A few months later, 8-year-old Rachel Belous was playing video games in her room.

“I just heard these shouts and I’m like, ‘What is going on?'” said Rachel.

It was another gift about those writings Belous submitted.

“A day or two before my birthday in June, I got the news. It was a wonderful birthday present,” said Belous.

Chicken Soup for the Soul is featuring Deb’s story in a chapter of their new book about breast cancer survivors.

Belous says she has always wanted to be a published author.

“Whatever life presents us, there are gifts,” she said.

All because of the scary chapter she won’t let define her.

The book is called “Chicken Soup for the Soul: Hope and Healing for your Breast Cancer Journey.” It’s being released on September 4.

If You Are Over 85, Why High Blood Pressure May Predict Longer Survival for the Elderly

An editorial just published in Archives of Internal Medicine detailed findings that for the very elderly, those over 85, high blood pressure may indicate better health while lower numbers could mean trouble.

.http://newoldage.blogs.nytimes.com/2012/08/08/for-the-very-old-a-surprise-in-blood-pressure-readings/#more-12997

Sleep Disorder Symptoms and the Impact on Your Brain

Sleep Disorder Symptoms can occur from a variety of possible causes including stress, menopause, breathing disorders, restless leg syndrome and light. Some research recommends more exposure to the “right” kind of light. The reduction in the amount of light that reaches the retina in the older adult is substantial. The retina of a typical 60-year-old receives only about one-third of the light that the retina of a typical 20-year-old receives. The older we are the more sensitive the eyes become to light which magnifies the problem. Light hitting the retina suppresses the production of the hormone melatonin, which alerts the body throughout the day, and induces sleep with darkness. 

With light, the body sets the internal 24 hour body clock. If we remain indoors in a dimly lit room during the day and have aging eyes, it becomes more difficult for our body cycles to regulate resulting in potential sleep problems. Technology also plays a role in our sleep disorder symptoms.  Any sort of light can suppress melatonin, but recent experiments have raised questions about one type in particular: the blue wavelengths produced by many kinds of energy-efficient light bulbs and electronic gadgets such as computers, cell phones, and televisions.  The preliminary study results showed that the longer and more blue wavelengths the eye is exposed to before going to bed, the longer it takes to fall asleep. It appears to suppress the melatonin. If you are rested, the brain performs better. 

The results also showed that the blue light exposure caused increased alertness and recall. It also increased performance on tests by 50-70% compared to people exposed to the old types of light bulbs, not energy efficient, and fluorescent monitors. The research is still in its early stages. 

If you are experiencing sleep disorder symptoms, try the following: 

-Expose yourself to sunlight during the day to keep your body clock, the circadian rhythms, functioning correctly.

-Make sure you do not have a health condition making sleep difficult such as sleep apnea.

-Get some exercise during the day. A slow walk is better than sitting.

-Have a fairly consistent sleep schedule

-About 90 minutes before going to bed, dim the lights and stop using electronic devices. Reading is better than television for something to do.

-Sleep in a cool and darkened room. 

Let us know if altering your “light” schedule helps you sleep better and be more alert during the day. 

Managing Stress for Improved Health

We can’t do away with stress entirely in our lives. We can learn to manage it and take positive action to minimize any negative consequences. We often feel stress when we lose a sense of control over our lives. We face constant changes in the work place frequently with more hours and less pay, caregiver responsibilities for our parents and our children, and little personal time. While everyone experiences stress at times, a prolonged bout of it can affect your health and ability to cope with life. That’s why social support and self-care are important. They can help you see your problems in perspective…and the stressful feelings ease up.

Sometimes stress can be good like when you are planning a wedding.  For instance, it can help you develop skills needed to manage potentially threatening situations in life. However, stress can be harmful when it is severe enough to make you feel over­whelmed and out of control.

Strong emotions like fear, sadness, or other symptoms of depression are normal, as long as they are temporary and don’t interfere with daily activities. If these emotions last too long or cause other problems, it’s a different story.

Symptoms of Stress

According to the Centers for Disease Control, Common reactions to a stressful event include:

• Disbelief and shock
• Tension, irritability or anger
• Fear and anxiety about the future
• Difficulty making decisions
• Being numb to one’s feelings
• Loss of interest in normal activities and appetite
• Nightmares and recurring thoughts about the event
• Increased use of alcohol and drugs
• Sadness and other symptoms of depression
• Feeling powerless or crying
• Sleep problems
• Headaches, back pains, and stomach problems
• Trouble concentrating

Tips for Self-Care

T    The best ways to manage stress in hard times are through self-care:

• Avoid drugs and alcohol. They may seem to be a temporary fix to feel better, but in the long run they can create more problems and add to your stress. Avoid caffeine if it makes you jittery.
• Find support. Seek help from a partner, family member, friend, counselor, doctor, or clergyperson. Listening and sharing your problems and stress really can lighten the burden.
• Connect socially. After a stressful event, it is easy isolate yourself. Make sure that you are spending time with loved ones. Consider planning fun activities with your partner, children, or friends.
• Take care of yourself.
  • Eat a healthy, well-balanced diet
  • Exercise regularly
  • Get plenty of sleep
  • Take a walking break if you feel stressed out
  • Maintain a normal routine
  • Get more organized such as a “to do” list, reduce noise and clutter

In a 2006 UCLA study and others, focusing on one task at a time produces better and faster results than multi tasking. A Vanderbilt 2006 study in “Neuron” suggests that the control center in the frontal lobes is incapable of processing two decision operations at once resulting in a bottleneck in processing.

Perhaps the best advice I was given is that we will never have all the information we need to make a decision so you do the best with the 80% of input. If you make it too late and reach the deadline, you have no time to make modifications.