Well: Schizophrenic and Wanting to Connect

I still remember the first group therapy session I went to after I got out of the hospital. I was 20 and had been diagnosed as schizophrenic after a road trip that took me from Colorado to the United Nations building in New York City, my mind riddled with notions of good and evil, demons and angels, and a determination to save the world. Now I was in something of a state of shock, having come to understand that amid the delusions and paranoia that swarmed through my head I was, in reality, insane.

A constant need to move felt like ants crawling over my skin, a side effect of the antipsychotic medications I had been prescribed. Every second of every day, I felt like clawing out my eyes and tearing out my hair because I just couldn't sit still.

I held up my front, though. I smiled when I thought I had to and tried to be nice to people. Laughter, however, was not something that was possible, and wouldn't be for a long time.

The group was a dual-functioning therapy technique to address both mental health issues and drug abuse. I had been assigned to it after disclosing that I had a marijuana habit. The doctors had told me that therapy groups were an integral part of my getting better. I agreed to go only to get out of the hospital prison and back home to my warm bed.

I sat in a circle with a melting pot of people. There was the construction worker still wearing dusty boots and clothes splattered with mud, and the depressed sorority girl, makeup and hair still impeccable. The two had formed a friendship over their history with methamphetamine. There was the quiet bipolar Hispanic man who spoke only in short staccato sentences, and the rotund marketing guy who introduced himself by saying his drugs of choice were food, cocaine and marijuana.

I sat there looking at them, hands nervously trying to find a natural position. I could tell they were thinking things about me, adjudicating me on my appearance and facial expressions. While they nodded in a sort of feigned acceptance, I knew they were going to go back to their friends and joke about me, the schizophrenic kid who looked weird.

When it was my turn to speak, I stood and told them in a quiet voice, almost so quiet you couldn't hear the nervous wavering, that my name was Mike. "Hey Mike, welcome" rang the chorus in a strange unison. It seemed welcoming, but I knew they were waiting for their opportunity to strike. Summoning everything to get any words out, I told them that I had been an inpatient the previous week, where the doctors said I was schizophrenic, and that my drugs of choice were marijuana, cigarettes and, taking a cue from the marketing guy, food.

Having their eyes on me was a special kind of hell, as I stood there fidgeting and averting my gaze. They were all drilling holes into me, isolating my weaknesses and then laughing about them to themselves. They were wolves, chewing at and snapping my bones. I just wanted to get out, but I continued, and when I was done, I sat back down in the chair and lowered my head, refusing to say a thing or acknowledge anyone for the rest of the session.

How had it come to this? I had been happy in high school, popular even, unafraid of my own insecurities, unconcerned with what people thought of me. I can remember having friends from every different clique, every group and every grade. The ability to connect with people seemed so effortless then.

It's a goal I've been striving to reattain for the last eight years.

When you have schizophrenia, the overarching plot of the experience is the inability to tell whether the things you are thinking are actually taking place in reality. Was that inflection in your voice a signal that I should be more friendly — or more reserved? Was that laughter I heard over my shoulder about me or something totally innocuous? These are the kinds of things I ask myself daily.

Recovering from mental illness is a process. It takes diligence in therapy, a strong support system and habitually taking your meds. With different drugs, the paranoia has calmed down, though it is still there, a reminder I'm still sick. Learning to accept what that paranoia was telling me and being all right with it, that I would still be the same person whether or not people thought negative things about me, has been a big part of my recovery.

Since that first group therapy session, I've worked harder than you can imagine trying to perfect a state of normal. Regaining the ability to relate to others has been a driving force. I've studied books on body language, manners, neuroscience and behavior just to get any small grasp on being a normal person. I know that if I do it right, and successfully connect with another human being, I feel giddy. But more often the interactions are a bit off, or a lot off, though not the end of the world.

Needless to say, it should be obvious that dating is hard for me. But I have friends, and they all know that I have schizophrenia and don't seem to mind. They seem to accept that mental illness is a disease and not some defect of self. I can see the stigma lessening day by day, although a lot of people are still afraid of it. It's nothing that a few little jokes and a sense of humor often can't fix. Still, I know many others with schizophrenia who don't have it as easy, who suffer every day, and I feel for them because I've sure been there.

It takes work, a lot of work, to get better, but it can be done. It has been a long road from that first group therapy session. But life is nothing if it's not a road.

Michael Hedrick, a writer and photographer in Boulder, Colo., is the author of the novel "Connections: The Journey of a Schizophrenic." He tweets bad jokes on Twitter at @thehedrick.

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Phys Ed: How to Get Fit in a Few Minutes a Week

Phys Ed

Gretchen Reynolds on the science of fitness.

High-intensity interval training, a type of workout that consists of very brief bouts of very strenuous exercise, has become enormously popular in recent years. A main reason is that although such workouts are draining, they can be both very effective and very short, often lasting only a few minutes.

But people take notably different approaches to this form of exercise. Some complete only one sustained, all-out, four- or five- minute bike ride or sprint — a single interval — and then are done. Others practice standard interval training, involving repeated brief bursts of almost unbearably taxing exertion, interspersed with restful minutes of gentler exercise. Some people perform such sessions two or three times per week; others almost every day.

The science of intensive interval training has, though, been lagging behind the workout's popularity. Past studies of HIIT, as the practice is commonly known, had established that as measured by changes in cellular markers, standard short-burst HIIT training may improve aerobic fitness up to 10 times as much as moderate endurance training. But scientists had not determined whether a single sustained interval likewise improves fitness, or the ideal number of HIIT sessions per week.

So to clarify those issues, researchers at two of the laboratories most noted for HIIT science set out to learn more about the best way to do interval training.

First, for a study published this month in Experimental Physiology, scientists at McMaster University in Ontario gathered 17 healthy young men and women and divided them into groups. Ten of them were asked to exercise on two separate days. On one day they completed a standard HIIT session consisting of four 30-second bouts of all-out, tongue-lolling effort on a stationary bicycle, alternating with four minutes of recovery between. On another day they completed a single uninterrupted interval lasting for about four minutes, by which time each rider had combusted the same amount of energy as during the stop-and-go session. Before and after the workouts, the scientists gathered blood and muscle samples.

Separately, the remaining seven volunteers did the continuous four-minute workout three times a week for six weeks. The researchers again collected blood and muscle samples, and monitored changes in the riders' athletic performance by having them ride as hard as possible for a specified period of time.

When collated and compared, the data showed that the physiological differences among the two groups of riders were notable and, in some ways, strange.

On the one hand, the scientists found no significant variations in how the muscles of riders in the first group responded to a single session of interval training, whether of the standard stop-and-go variety or a sole sustained effort. In both cases, the riders showed immediate, post-exercise increases in their blood levels of certain proteins associated with eventual improvements in endurance capacity.

But when the researchers checked blood and muscle tissue in the second group of riders after they had completed six weeks of single-interval training, some of the pending improvements seemed to have evaporated. These riders' muscle tissues now had only average — not augmented — amounts of the chemicals that help cells to produce more energy, a reliable marker of fitness. This finding was in stark contrast to the results of earlier work by the same researchers, in which they found that six weeks of standard short-burst HIIT exercise resulted in significant, sustained gains in these markers.

The implications of the new study are not altogether clear, said Martin Gibala, the chairman of the department of kinesiology at McMaster University and senior author of the study, but "it would appear," he said, "that there is something important, even essential, about the pulsative nature" of on-off HIIT training if you wish to reap sustained physiological improvements.

In more practical terms, before you riff on your current workout, check to see whether reliable science supports your improvisation.

That caution is underscored by the results of the other major new study of interval training, this one published this month in PLOS One and undertaken at the Norwegian University of Science and Technology in Trondheim, Norway. In it, scientists asked volunteers to perform a total of 24 standard HIIT sessions over either three or eight weeks, meaning that the volunteers exercised either three times per week or almost every day and sometimes twice on the same day.

At the end of the prescribed time, those who had completed three HIIT sessions per week had improved their endurance capacity by almost 11 percent. But those exercising daily displayed no such improvements and, in some, endurance declined. Only after those volunteers had quit training altogether did their aerobic capacity creep upward; after 12 days of rest, their endurance peaked at about 6 percent above what it had been at the start, suggesting, the researchers believe, that daily high-intensity interval sessions are too frequent and exhausting. In that situation, fatigue blunts physical adaptations.

The takeaway of both studies is that it is best, if you wish to perform high-intensity interval training, to stick to what is well documented as effective: a few sessions per week of 30- or 60-second intervals so strenuous you moan, followed by a minute or so of blessed recovery, and a painful repetition or four. Done correctly, such sessions, in my experience, get you out of the gym quickly and inspire truly inventive cursing.

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Well: Test Is Improved Predictor of Fetal Disorders

A test that analyzes fetal DNA found in a pregnant woman's blood proved much more accurate in screening for Down syndrome and another chromosomal disorder than the now-standard blood test, a new study has found. The promising results may change how prenatal screening for genetic diseases is done, though the test is costly and generally not yet covered by insurance for women at low risk.

The study, published on Wednesday in The New England Journal of Medicine, found that the fetal DNA test was 10 times better in predicting cases of Down syndrome than the standard blood test and ultrasound screening, and five times better in predicting the other disorder, Trisomy 18. It also greatly reduced the number of false-positive results.

It could prevent many women who would otherwise get the standard blood test from needing to confirm positive results with invasive tests like amniocentesis or chorionic villus sampling, which can be stressful, much more costly and carry small risks of miscarriage. "Nine out of 10 women who are currently being referred for further testing would not need invasive tests," said the lead author of the study, Dr. Diana Bianchi, the executive director of the Mother Infant Research Institute at Tufts Medical Center's Floating Hospital for Children.

A positive result on the DNA screening would still need to be confirmed with invasive tests, because in more than half the cases in which the newer test predicted a disorder, there was no chromosomal abnormality. But a negative result would provide confidence that these two major chromosomal disorders are absent.

"It's a better mousetrap, there's no doubt about that," said Dr. Michael Greene, director of obstetrics at Massachusetts General Hospital and co-author of an editorial about the study. "If the test is normal, the overwhelming probability is that your fetus is normal. There will be far fewer women who will be encouraged to have invasive testing, and, as a result, far fewer miscarriages."

The screen analyzes blood from women who are at least 10 weeks pregnant. At that point, about 10 percent of DNA in the blood will be fetal DNA from the placenta, Dr. Bianchi said.

Dr. Bianchi is a paid advisory board member for Illumina, one of the laboratories that performs the test, which is known as the cell-free DNA test because the fetal DNA floats freely in the mother's blood, not inside a cell. Illumina, which is based in San Diego, financed the study.

Dr. Greene, an associate editor at The New England Journal of Medicine, said that the study "would sort of be purer from an academic perspective if somebody else pays for it," but that companies are "the ones that are going to finance the research to get it to where it's marketable."

He added, "We can't have our cake and eat it too." He said the journal had rejected other cell-free DNA studies, but considered this one well done.

Experts said they expected the test would ultimately be offered to all pregnant women, but noted limitations. The test, costing $500 to $2,000, is not now typically covered by insurance for women at low risk for having babies with chromosomal abnormalities. Nor is it regulated by the Food and Drug Administration, because it is considered "laboratory developed," to be used by the lab that created them and not sold to other labs or companies, Dr. Greene said.

The test also appears to work inconsistently in very obese women. And it screens only for major chromosomal disorders and some sex-linked diseases.

"This is a very good screening test for what it's designed to screen for," said Dr. Ignatia B. Van den Veyver, a prenatal geneticist at Baylor College of Medicine. But, she added, "we're concerned that if women stop there, they miss the opportunity to have a diagnostic test like amnio that can detect other chromosomal abnormalities."

For now, this new technology, which became available in 2011, is primarily used for women deemed more likely to have babies with abnormalities because they are age 35 or older or have other risk factors. At least four companies offer the tests. Medical organizations have not recommended them for other women because of a lack of data showing they work in the general population.

The new study, which involved 1,914 pregnant women from diverse backgrounds at 21 medical sites around the country, is the first large study to evaluate the cell-free DNA screen in average American women. Most women in the study were younger than 30, had conceived naturally, and were pregnant with their first child.

Dr. Deborah A. Driscoll, a professor of obstetrics and gynecology at the University of Pennsylvania, who was not involved in the research, said that given this new evidence, "this should be a test that we can offer women universally."

The women received standard screening from their doctors, a blood test that identifies proteins or other biological markers associated with chromosomal disorders. Some also got ultrasounds examining the fetus's neck for fluid associated with Down syndrome.

Separately, and without knowing the results of the standard tests, technicians at the Illumina lab screened samples of the women's blood for three copies of chromosomes instead of the normal two, seeking to identify chromosomes for Down syndrome, and for Trisomies 18 and 13, often fatal disorders.

Researchers later checked whether babies were born with or without these conditions.

In the study, the rate of false positives for Down syndrome was 0.3 percent with the cell-free DNA screening, while the rate for standard screening was 3.6 percent, 12 times higher. The false-positive rate for Trisomy 18 was 0.2 percent with the DNA screening; the rate with standard screening was three times that. Not everyone received standard screens for Trisomy 13, so complete comparisons could not be made.

The DNA screen was correct in predicting Down syndrome 45.5 percent of the time, while the rate for standard screens was 4.2 percent. The DNA screen accurately predicted babies with Trisomy 18 almost 41 percent of the time, five times better than standard screening, whose rate was 8 percent.

The cell-free DNA screen worked equally well in first, second or third trimesters, and in high- and low-risk women." Since positive tests are often wrong, women should get positive findings verified with amniocentesis or C.V.S., experts aid.

"The greatest risk is that the test will be oversold or over-interpreted and that women won't take the step of an invasive diagnostic procedure before they do something irreversible like terminate a pregnancy," Dr. Greene said.

In the study, one of the five fetuses with Down syndrome was aborted, one of two with Trisomy 18 was stillborn, and the sole fetus with Trisomy 13 died in utero. The other five chromosomally abnormal babies were born alive.

Jennifer Fontaine, 29, of Groveland, Mass., was not in the study, but chose cell-free DNA screening last year after standard screening showed an elevated risk of Trisomy 18 in her fetus. She was offered amniocentesis, but she said, "I wanted the noninvasive procedure." Her DNA screen was negative for Trisomy 18, and her daughter, Morgan, was born healthy.

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Andrew Pollack contributed reporting.

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This post has been revised to reflect the following correction:

Correction: February 27, 2014

An earlier version of this post misspelled the surname of a prenatal geneticist at Baylor College of Medicine. She is Dr. Ignatia B. Van den Veyver, not van der Veyver.

A version of this article appears in print on 02/27/2014, on page A17 of the NewYork edition with the headline: New DNA Test Better at Predicting Two Disorders in Babies, a Study Finds.

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Well: How to Get Fit in a Few Minutes a Week

Phys Ed

Gretchen Reynolds on the science of fitness.

High-intensity interval training, a type of workout that consists of very brief bouts of very strenuous exercise, has become enormously popular in recent years. A main reason is that although such workouts are draining, they can be both very effective and very short, often lasting only a few minutes.

But people take notably different approaches to this form of exercise. Some complete only one sustained, all-out, four- or five- minute bike ride or sprint — a single interval — and then are done. Others practice standard interval training, involving repeated brief bursts of almost unbearably taxing exertion, interspersed with restful minutes of gentler exercise. Some people perform such sessions two or three times per week; others almost every day.

The science of intensive interval training has, though, been lagging behind the workout's popularity. Past studies of HIIT, as the practice is commonly known, had established that as measured by changes in cellular markers, standard short-burst HIIT training may improve aerobic fitness up to 10 times as much as moderate endurance training. But scientists had not determined whether a single sustained interval likewise improves fitness, or the ideal number of HIIT sessions per week.

So to clarify those issues, researchers at two of the laboratories most noted for HIIT science set out to learn more about the best way to do interval training.

First, for a study published this month in Experimental Physiology, scientists at McMaster University in Ontario gathered 17 healthy young men and women and divided them into groups. Ten of them were asked to exercise on two separate days. On one day they completed a standard HIIT session consisting of four 30-second bouts of all-out, tongue-lolling effort on a stationary bicycle, alternating with four minutes of recovery between. On another day they completed a single uninterrupted interval lasting for about four minutes, by which time each rider had combusted the same amount of energy as during the stop-and-go session. Before and after the workouts, the scientists gathered blood and muscle samples.

Separately, the remaining seven volunteers did the continuous four-minute workout three times a week for six weeks. The researchers again collected blood and muscle samples, and monitored changes in the riders' athletic performance by having them ride as hard as possible for a specified period of time.

When collated and compared, the data showed that the physiological differences among the two groups of riders were notable and, in some ways, strange.

On the one hand, the scientists found no significant variations in how the muscles of riders in the first group responded to a single session of interval training, whether of the standard stop-and-go variety or a sole sustained effort. In both cases, the riders showed immediate, post-exercise increases in their blood levels of certain proteins associated with eventual improvements in endurance capacity.

But when the researchers checked blood and muscle tissue in the second group of riders after they had completed six weeks of single-interval training, some of the pending improvements seemed to have evaporated. These riders' muscle tissues now had only average — not augmented — amounts of the chemicals that help cells to produce more energy, a reliable marker of fitness. This finding was in stark contrast to the results of earlier work by the same researchers, in which they found that six weeks of standard short-burst HIIT exercise resulted in significant, sustained gains in these markers.

The implications of the new study are not altogether clear, said Martin Gibala, the chairman of the department of kinesiology at McMaster University and senior author of the study, but "it would appear," he said, "that there is something important, even essential, about the pulsative nature" of on-off HIIT training if you wish to reap sustained physiological improvements.

In more practical terms, before you riff on your current workout, check to see whether reliable science supports your improvisation.

That caution is underscored by the results of the other major new study of interval training, this one published this month in PLOS One and undertaken at the Norwegian University of Science and Technology in Trondheim, Norway. In it, scientists asked volunteers to perform a total of 24 standard HIIT sessions over either three or eight weeks, meaning that the volunteers exercised either three times per week or almost every day and sometimes twice on the same day.

At the end of the prescribed time, those who had completed three HIIT sessions per week had improved their endurance capacity by almost 11 percent. But those exercising daily displayed no such improvements and, in some, endurance declined. Only after those volunteers had quit training altogether did their aerobic capacity creep upward; after 12 days of rest, their endurance peaked at about 6 percent above what it had been at the start, suggesting, the researchers believe, that daily high-intensity interval sessions are too frequent and exhausting. In that situation, fatigue blunts physical adaptations.

The takeaway of both studies is that it is best, if you wish to perform high-intensity interval training, to stick to what is well documented as effective: a few sessions per week of 30- or 60-second intervals so strenuous you moan, followed by a minute or so of blessed recovery, and a painful repetition of four. Done correctly, such sessions, in my experience, get you out of the gym quickly and inspire truly inventive cursing.

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Recipes for Health: Winter Cabbage With a Mediterranean Flair

One of the things I appreciate about this produce-limited time of year is that it forces me to devote a week of Recipes for Health to cabbage. I love this nutrient-dense cruciferous vegetable for many reasons: the way it sweetens as it cooks in the pan; the price per pound; the way it is comfortable in a soup or a pie, a stew, a gratin or a salad, a stir-fry or a timbale. Yet I sometimes forget to pay attention to cabbage. It can be overshadowed by other winter vegetables like kale, its more fashionable cousin.

The extraordinary health benefits of cabbage reside mainly in its abundant polyphenols and glucosinilates. These micronutrients are proving to have antioxidant and anti-inflammatory properties that help the body fight disease. Cabbage is also an excellent source of vitamin C and a good source of vitamin A.

I was all set to focus on recipes from Russia and Eastern Europe this week, and I did come up with some fabulous pirozhki, the classic Russian little oval pies. But as so often happens when I am exploring recipes and experimenting in my kitchen, I could not get away from the Mediterranean, where cabbage is also widely appreciated. So this week you will taste a delicious soup that is seasoned with Parmesan rinds, Italian bruschetta topped with pan-cooked cabbage, as well as a spicy Tunisian chakchoukah, a vegetable stew that is traditionally mainly peppers and tomatoes, but in this version features cabbage, peppers and tomatoes, with eggs poached right in the stew.

Cabbage and Parmesan Soup With Barley: A comforting soup with texture and bulk provided by barley.

Cabbage and Ricotta Timbale: A light timbale with a sweet, delicate flavor.

Cabbage Pirozhki: A rich-tasting Eastern European pastry that isn't rich at all.

Bruschetta With Cabbage Braised in Wine: Long-simmered cabbage provides a sweet flavor for this bruschetta.

Cabbage and Pepper Chakchoukah: This is a spicy Tunisian pepper stew with poached eggs.

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Ask Well: Ask Well: Parabens in Our Lotions and Shampoos

A

Parabens are old-time chemical preservatives – they were first introduced in the 1950s after bacteria-contaminated facial lotions caused a small outbreak of blindness. Today, they are used in a wide range of personal care items – from cosmetics to toothpaste, as well as some foods and drugs.

It is partly because of their stable history that the Food and Drug Administration describes them as safe, at least in the trace amounts – 0.01 to 0.3 percent – found in most consumer products.

However, and here's where the answer gets complicated, in recent years, environmental health advocates have challenged that conclusion. Their concerns grew after a 2004 study found paraben compounds in breast cancer tumors.

Although no real link to the cancer was established, research has also found that parabens are weak estrogen mimics, capable of altering cell growth in culture, and may also act as endocrine disruptors, which can disrupt the normal function of hormones and interfere with development. The F.D.A.'s position is that parabens are too weak in this regard to cause any real concern.

The primary issue has become their ubiquity. "Parabens are found in between 13,000 and 15,000 personal care products," said Janet Gray, director of the science, technology and society program at Vassar College. "So we are not talking about a single exposure but a more pervasive one."

A 2006 analysis by the Centers for Disease Control and Prevention found evidence of parabens in more than 90 percent of people tested, with women – who use more cosmetics – registering higher levels than men. And a recent report in Environmental Science & Technology found that parabens were so common in products like baby lotion that infants may also receive a relatively high dose.

Researchers like Dr. Gray say we need to get a much better sense of such potentially riskier exposures. "The standard model of studying one paraben at a time isn't telling us what we need to know," she said. "It's the bigger picture that matters."

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Do you have a health question? Submit your question to Ask Well.

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This post has been revised to reflect the following correction:

Correction: January 31, 2014

An earlier version of this post misstated the name of a scientific journal. It is Environmental Science & Technology, not Environmental Science & Toxicology.

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The New Old Age Blog: The Policy Lapsed, but No One Knew

Sometimes you do everything right and it still goes wrong.

Michael Pirron runs a technology consulting company in Richmond, Va. For some time, he fretted about his parents, about what would happen if, like most older Americans, they needed expensive care as the years passed. They were still young-ish and comparatively healthy, but his father's mother had lived to be 105.

So in February 2001, when David Pirron was 67 and his wife Anne was 59, Michael helped them buy joint long-term care insurance policies, with benefits that rose annually, from John Hancock. When the time came, it would provide up to $600,000 to pay for home care, adult day care, assisted living or a nursing home.

"I'm an only child," Mr. Pirron told me. "I'm not independently wealthy. This was the way I could be sure they had care when they needed it."

The older Pirrons gave him their power of attorney, as experts perennially urge. They signed the form making their son the third party designee that John Hancock would notify of policy changes or anything that could cause the policies to lapse. But, to ensure that they remained in force, Michael Pirron made arrangements with his parents' bank. "I made sure my dad had auto-pay so that the premiums got paid every month," he said.

In the years that followed, the couple downsized from a house in Washington to a condo in Fredericksburg, Va., an hour away from Michael. They faithfully paid about $50,000 in long-term care premiums over a decade, Michael estimates, and never made a claim.

But the crisis arrived, as it often does. By 2012, Mrs. Pirron was falling and had developed psychiatric symptoms, and her husband had become too confused and forgetful to remain her caregiver. Michael Pirron called John Hancock to ask about the care options covered by his parents' insurance.

"Their answer was, essentially, 'What policy?'" he said. The policies had lapsed eight months earlier, and it was too late to send in the past due amount and get them reinstated.

The insurer had sent the couple warnings that their insurance was about to be terminated, but they didn't understand the letters, which Michael eventually found stuffed in a drawer. He also figured out why the bank stopped paying premiums: His father had gone to his branch — without telling him — to stop auto-payments on a different insurance policy and had mistakenly turned off payments to John Hancock instead.

But what about the third-party notice the insurer was supposed to send Michael Pirron? John Hancock insisted its records showed it had sent the required letter; he says he never received one.

In a June 2012 letter, John Hancock officials said the company would not reinstate the policy. "We believe this action to be consistent with both our business model and regulatory obligations," the company wrote. It added, "We sincerely regret any personal distress resulting from our decision."

There was plenty of that. Instead of tapping their insurance benefits to pay for assisted living, the Pirrons sold their condo at a loss and moved to a small apartment in Richmond, Va., where Mrs. Pirron receives care from a PACE program through Medicaid.

Michael Pirron complained to the state Bureau of Insurance, which investigated but ultimately took no action; insurers aren't required to prove they have contacted third parties. He had attorneys look into the matter, but decided he couldn't undertake the six-figure cost of a lawsuit.

So he turned to the Virginia legislature, where Representative Jennifer McClellan has introduced HB719, which would require insurers to send lapse or termination notices to both policyholders and third parties via certified mail or commercial services like FedEx or UPS. That would provide proof that companies notify customers, or don't.

"It's too late for my parents, but I want to make sure this doesn't happen to anyone in Virginia, or anywhere, ever again," Michael Pirron said.

The state AARP chapter has lobbied for the bill and the state Alzheimer's Association has endorsed it. David DeBiasi, advocacy director for AARP Virginia, thinks the bill has a shot, partly because "it will make sense to those trying to limit the size of entitlement programs and the escalating cost of Medicaid."

Had John Hancock spent a few dollars for certified mail, taxpayers might not be footing the bills the Pirrons intended to handle themselves. Insurance industry lobbyists don't seem to be opposing the measure, Mr. DeBiasi said.

But they could if, as Michael Pirron hopes, this idea takes off nationally.

"Ultimately, policyholders will pay the cost, and the cost is not just the postage," said Jesse Slome, who heads the American Association for Long-Term Care Insurance. He points out that of the roughly 300,000 policies sold annually, more than 9 percent lapse the first year and another 6 percent the second, so that companies would need workers and systems to send and track thousands of certified letters.

"When you don't pay your credit card bill, you don't get a registered letter," Mr. Slome said. But of course, credit card companies don't target people whose age brings increasing risk of dementia.

Insurance regulation falls mostly to individual states, so even if legislatures or insurance commissioners adopt this requirement, years will pass before most policyholders have such protection.

In the meantime, cases like this demonstrate anew how vigilant families need to be. If your older relative has a long-term care policy, photocopy the page listing the company, policy number and claims contact information. Keep the insurance company updated on new addresses, yours (if you are the third-party designee) and your relative's. It wouldn't hurt, if the policyholder is becoming forgetful, to check bank statements or call the company to be sure premiums are paid.

Now, Michael Pirron is worrying about care for his father, recently diagnosed with early dementia.

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Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."

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