I have decided to make a former client my role model. I met him half a dozen years ago, when he was in his early eighties and moving to a retirement community. As we began planning his move, he said, “I lost my wife three years ago. Sorting through our belongings makes me feel like I am losing her all over again?I wish I could go away and come back after the move.” And so he became our first “I’d rather go on vacation” client. Since then, I have often thought about his ability—and his willingness—to articulate his feelings and take a course of action that worked for him.

I met him again several years later and learned that he had moved to a different apartment in the community, to be near a woman he had met. “She introduced me to the literary club,” he said. “It consists of me and five women. We meet every Thursday before dinner, laugh, drink and talk about no literature.” Then he continued, “She is a very interesting woman—an artist." The door to her apartment, across from his, bore a sign, "Outrageous older woman lives here.” He introduced me to her. The sign was appropriate.

The former director of a multi-hospital system, he still taught in the graduate program he had helped found at a nearby university and had lunch with current and former students regularly. Before I left, he confided, “This move [to the retirement community] has so exceeded my expectations. I never expected that my ninth decade would be so rich, stimulating and enjoyable.”

I met with my former client again a few weeks ago. Sadly, I learned that his friend the artist had passed away. He was on his way to the chess club, where he and other members met regularly with the chess club of an inner city high school. He was leaving soon, he explained, for the second half of an oral history project conducted by the American Hospital Association. They had interviewed him in 1980 in recognition of his leadership role in the industry, and they wanted to meet with him again, twenty-eight years later. In preparation, he was reviewing his professional accomplishments since that time.

I thought to myself, the oral history people have it all wrong. What is important here is not his contribution to the health care industry; it’s the way he lives life now. A typical baby boomer, I plan to work forever, but when I am in my eighties, I hope I’ll have the same comments about my ninth decade, and that I will form new, meaningful relationships, laugh, and give back to others. A legacy is not something you leave, I have decided, it’s something you make. My former client is my role model because he has made a great one. I hope I can do the same.

A Caregiver’s Guide to Alzheimer’s Disease: 300 Tips for Making Life Easier, authored by Roger Brumback, Patricia Callone, Connie Kudlacek, Janaan Manternach and Barbara Vasiloff, was recommended to me by Natalie Davis, who instructs activity director certification courses, and whose father died of Alzheimer’s disease a year ago.

The book is divided into three sections: tips for making life easier during the progression of the disease, helpful information about Alzheimer’s and related dementias, and resources for people with Alzheimer’s as well as their caregivers and loved ones. The book identifies seven key functions of the brain in the pre-Alzheimer’s stage. These functions deal with memory, language, complex tasks, social skills, judgment and reasoning, ambulation, and the senses. During the normal aging process, a person experiences a slowdown in these functions. Dementia, however, causes a progressive loss in all of these areas. The caregiver must nurture the skills that remain, whether they are cognitive, social or physical.

In addition to the pre-Alzheimer’s stage, A Caregiver’s Guide to Alzheimer’s Disease breaks down the stages of the disease and discusses the changes that occur in the brain, which affect behavior. The book also offers practical tips for maintaining quality of life as much as possible, and mentally engaging a person with Alzheimer's to help slow cognitive decline. The recommendations below have been excerpted from the book.

Following are some games that can help preserve the cognitive abilities of a person who has Alzheimer’s. Try engaging that person’s memory by having him or her:

• Verbally identify household objects in order to promote language skills.
• Identify people and objects in photographs.
• Spend time doing activities enjoyed before the onset of the disease.
• Play games that involve movement, such as bean bag tossing and following exercise tapes.
• Decorate for the holidays. Not only will this make the environment more stimulating, but it will also cue the patient to the season.

The ability to perform complex tasks that were learned early in life can remain late in the disease progression. Help the person with Alzheimer’s by nourishing the skills that remain. Some of these may involve:

• Long-term memories. Watch films or listen to music from that person’s youth, discuss books he or she has read, past vacations, favorite family members or past personal achievements—use your imagination!
• Interests or hobbies learned before the disease. Invite the Alzheimer’s patient to participate in activities that involve using skills he or she still has; this could include working on a jigsaw puzzle, playing a musical instrument, or playing card games.
• Socializing. Encourage participation in any activity that involves other people, such as adult day care programs, entertainment events, socials, neighborhood associations, friends and family. Early Alzheimer’s patients in particular may feel inferior because of their cognitive losses. They should be reassured that they can continue to be included in social gatherings.
• Sensory perception. Try painting different colors in a single room, or different rooms in various colors. Increasing lighting can improve the patient’s concentration and may also reduce the risk of falls. Decorate the house, windows and table settings. Play music for stimulation during activities or to provide calm at rest times.

Here are a few caregiver tips for making life easier when caring for an Alzheimer’s patient:

• Label the contents of drawers and cupboards.
• Mark the passage of time on calendars by drawing an “X” on the days that have passed. Write down events to be looked forward to in the future.
• Preserve private time for yourself. Dementia patients become dependent on their caregivers, and can become distressed when you are absent. Set privacy limits before this happens.
• Establish a hygiene routine. Although the importance of hygiene diminishes for dementia patients, being clean and well dressed increases their dignity and self-esteem.
• Keep a log of behavior disturbances. Make a note of what may have triggered the behavior, the time of day it occurred, and any other details you think are relevant. Look for patterns so you can avoid them in the future.
• Delegate tasks now to prepare for the time when you will need help.
• Lower the pitch of your voice. Don’t shout, as it may cause agitation.
• Allow extra time for daily tasks to compensate for slowed reactions and reduced abilities. Don’t rush, as this can create a stressful situation unnecessarily.
• Use easy-to-manage clothing, such as items that close in front rather than over the head, and use Velcro fastenings when possible.
• Serve food in plates or bowls with a lip or rim (like a pie plate) to make it easier to get food on the fork. Attaching foam rubber to utensil handles will make them easier to grip. Keep finger foods on hand for snacks.
• Consider getting a pet. Small animals such as birds, fish and gerbils can bring joy and the satisfaction of being needed to the dementia patient, and they are relatively easy to care for.
• Childproof the environment. Install childproof locks on cabinets, put cleaners and sharp objects out of reach, remove objects that can be easily swallowed, and hide breakable valuables.

Internet Resources

Following are some helpful online resources for caregivers of people with Alzheimer’s.

• Find a wealth of information on numerous health-related topics at www.medlineplus.gov, which is co-sponsored by the U.S. National Library of Medicine and the National Institutes on Health (NIH).
• Read the Medical Library Association’s top ten most useful medical sites.
• The National Institute on Aging focuses on aging research and sponsors www.alzheimers.org. This link will take you to the Alzheimer’s Disease Education and Referral (ADEAR) Center.
• The Alzheimer’s Association is one of the nation’s leaders in providing information, education and support to people with Alzheimer’s, their families and caregivers.
• The Fisher Center for Alzheimer’s Research Foundation, one of the world’s leading research groups, “collaborates with the other leading research institutions around the world in the global pursuit for the cause, care and cure of Alzheimer’s disease.”
• The Disease Management section of The Alzheimer’s Research Forum is especially helpful.
• Find health and wellness information for older adults at www.NIHseniorhealth.gov. The site covers a wide breadth of topics, which are alphabetically arranged and easy to locate.

Extra! Extra! Read all about it! Surprising new guidelines from the American Academy of Pediatrics suggest that children as young as eight should be started on cholesterol-lowering drugs. Not surprisingly, cholesterol has become one of the most popular topics of conversation in my office. Patients are worried about reaching that “magic number” on their lab test and are also concerned about the side effects of medications used to attain it.

An abnormal cholesterol level is most often a symptom of an underlying imbalance in the body. In naturopathic medicine, we look for the imbalance, which is often lifestyle-induced, and work to correct it. Once this happens, the body lowers or raises cholesterol to that magic number on its own. Yes…I said “raises.” Cholesterol can be too low.

What the Heck is Cholesterol, Anyway?

Cholesterol is a waxy, fatty substance that is made and regulated by our livers. I often ask patients, “Why would your liver try to kill you?” This usually gets a chuckle, but more importantly, it allows a patient to pause and think. Is this the Great Liver Uprising of 2008? Is it a liver conspiracy to take over the world? No! Naturally, our livers are not trying to kill us. They are trying to help us. So, why are all these livers elevating cholesterol? Why are our bodies going through all the trouble of making cholesterol? Because it is an incredibly important substance to have around. That’s why.

What Has Cholesterol Done for You Lately?

The body will increase output of cholesterol when it senses a need for it. Here are just some of the important functions of cholesterol:

• Cholesterol is an important part of the membranes of our cells. It allows the membranes to be “fluid” so that cells can take in nutrients, expel waste and communicate with each other.
• Cholesterol is a building block for many of our hormones. The body turns it into progesterone, testosterone, estrogen, DHEA, and cortisol (a hormone made by the body in response to stress and inflammation). If the body senses the need for more of these hormones, it will ramp up cholesterol production. By the way, it is the inflammation that creates the injuries in our arteries, not cholesterol. The body initially lays cholesterol down in these injured areas to act like an oil slick, so blood can slide by.
• The body makes vitamin D from cholesterol. Vitamin D is a crucial part of calcium balance and bone health. Recent research suggests it is also imperative for other functions, including maintenance of mental health, enhancement of the immune system, and prevention of several types of cancer. Most Americans are thought to be absolutely deficient in vitamin D.
• One of cholesterol’s most important functions is to support the brain and nervous system. Cholesterol helps nerve cells known as neurons to conduct the impulses necessary to communicate with each other. In short, it helps us think. Imagine how important cholesterol is for learning and the formation of memories. Now, imagine what giving cholesterol-lowering medications to children who are still cognitively developing will do. Now you see why the recommendation from the AAP is so surprising.
• Cholesterol is used by the liver to make bile acids. Bile acids are released into the intestines when we eat. Their purpose is to mix fats with the water-soluble enzymes that digest them. These fats, including fat-soluble vitamins and the oh-so-important omega-3s, are essential to every system of the body.

So, you see, cholesterol is not all bad. It boils down to this: if you struggle with high cholesterol, your body is trying to tell you something. Are you listening?

Let’s continue the discussion next month. Until then…

Take care of your (whole) self—

Amy Bader, ND

In part 1 of this series on the disposal of adult diapers, I discussed what materials—and how much of those materials—are ending up in the landfill via used adult disposable diapers. In this post, I want to examine the disposal and potential compostability of these used diapers, pads, underpads, liners and other incontinence products.

For most incontinence product users, the process of disposing of adult diapers is the same as it is for those disposing of children’s diapers; most national waste management companies allow consumers to simply put used diapers into the waste stream along with other garbage (check with your local waste management company to be sure they do not have some special requirements). Given the numbers I mentioned in my last post, that’s a lot of dirty diapers. However, if there is one bit of good news here, it is this: viruses contained in human feces have not yet shown any danger to waste collection workers based on current collection methods.

These diapers are thrown away for one major reason: it is ?the norm.? To date, there are no truly compostable diapers available on the market, although the technology to make such diapers does exist. In my opinion, the technology can—and will—only work if government regulation requires diaper manufacturers to produce such products. Why? Simply put, even if all of the non-compostable products (e.g., petrochemical plastics, glue, tapes, etc.) in adult diapers were replaced by compostable materials, waste management companies would have to be assured that each and every diaper entering the waste stream was completely compostable, and free of non-biodegradable materials. Moreover, the process for full compostablility will only work if there is 100% compliance by all manufacturers to produce a diaper that is 100% compostable. Otherwise it will be nearly impossible for waste management companies to process this stream of dirty diapers.

As consumers, all that we can do for now is to encourage our federal, state and local governments to recognize the amount of non-compostable trash being generated by the users of adult disposable diapers and to propose proactive solutions. The industry knows of the technology to completely eliminate this issue. However, as I’ve stated before, I am no expert on this matter and welcome all comments from readers, informed individuals and bona fide experts.

Next time I’ll tackle how incontinent product users can help the environment, reduce the carbon footprint left by disposable diapers, and save money at the same time.

Your Partner in Comfort,

Gary

Reverse mortgages understandably have their fair share of both advocates and critics. A financial tool to help seniors pay for home improvements, stay in their home, and increase their standard of living, the downside of reverse mortgages is that the cost can be high. I recently met with a family who asked me to help them talk with their aging parent about moving. The senior and her adult children shared with me their concerns about why they thought it was a good time for her to move. The mom—let’s call her Susan—recognized she needed some help with preparing meals and housekeeping, but really wanted to stay at home. The challenge was finding the money and the services to help Susan stay home for as long as possible, and in a way that would meet her daily needs and give her family some peace of mind, knowing that she would be safe. This gave us the opportunity to talk about reverse mortgages.

First, to be eligible, you must be over sixty-two years of age, own your home, and be living in it as your primary residence. The amount you are eligible for depends on your age, interest rates and the value of your home. Most reverse mortgages are set up so the home owner can receive monthly payments.

Advantages

• The reverse mortgage can be set up as a monthly payment, line of credit or a lump sum—whatever works best for the senior.
• No matter how the reverse mortgage is set up, the home owner does not make any monthly payments.
• No monthly payment is due from the home owner unless he or she dies, moves or sells the home. At that time the loan is due in full, plus interest and fees.
• The home owner can receive monthly income from a reverse mortgage as long as he or she lives in the home as a primary residence. A home owner could potentially continue to receive monthly payments even after the loan balance is higher than the amount that the house is worth.
• Neither the home owner nor his or her heirs will ever owe more than the home is worth, no matter how many payments are received or how high the interest rates become.
• It’s fairly easy to qualify for this loan since credit scores and income are not part of the qualification process.

Disadvantages

• The closing costs are high. The senior must pay origination fees that are about double what they are for conventional mortgages and mortgage insurance. The interest rates are adjustable.
• For seniors who depend on Medicaid or other state or federal programs, it’s important to consider if reverse mortgage payments will affect their eligibility.
• The senior is required to attend counseling by an independent HUD counselor prior to receiving a reverse mortgage. These are complex loans and this is a measure of consumer protection.

Possible Alternatives

• A line of equity may be an alternative. There are fewer fees, and the money is available on an as-needed basis, but it requires monthly payments.
• Refinancing the home with a conventional mortgage may save mortgage insurance fees that a reverse mortgage would require. However, this too requires monthly payments.

As a potential consumer of any financial tool, be cautious and seek out accurate information before making a decision. If you are looking for information on reverse mortgages, I suggest you talk with a HUD counselor or someone impartial. Reverse mortgage officers may be prone to selling only the advantages since they get paid when you take out a reverse mortgage. Real estate agents may be prone to selling only the disadvantages of them, as they get paid when you sell your home. Your best bet is to find an impartial advisor such as a financial planner (whose brokerage doesn’t sell reverse mortgages), an elder law attorney or a certified reverse mortgage counselor, all of whom will be able to share practical information to help you make your decision.

Here are a few links of interest to help you get started:

Reverse Mortgage Calculator

Find a HUD Counselor

Find a HUD-Approved Reverse Mortgage Lender

Affordability is a key ingredient in any successful long-term care plan. That is why the premium cost is often the most important factor to consumers who are considering the purchase of LTCI.

“Will My Premiums Ever Increase?”

One of the most common questions I hear is: “Will my premiums ever increase?” The answer is this: there are a couple of scenarios in which LTCI premiums could increase. I will try to explain one in this article and follow up with the second in a future article.

The first scenario involves a choice the policyholder makes regarding inflation protection. Most LTCI policies have automatic inflation protection built into the policy design from the beginning; in such cases the premium is designed to stay level for the life of the policyholder. The benefits increase each year, but the premium remains the same.

Inflation Protection: What You Need to Know

Some insurance carriers offer a different kind of inflation in which the policyholder starts out with no automatic inflation protection; instead, benefit increases would be offered every three years or so. These increases can usually be accepted or declined by the policyholder. This means that your premium would increase every three years for the rest of your life or until you start receiving policy benefits.

The problem with this inflation protection choice is that the policyholder is three years older when each offer of extra benefits is made. The cost of the added benefits is based on the later age, not on the age of the policyholder at the inception of the policy. This can result in a significant increase in premiums in later years. Some consumers simply drop these policies after a while, as they just can?t afford to continue paying premiums that are so much higher than the cost of the original premium.

Long-term Effects of Premium Increases

Group policies often offer this kind of inflation protection to stay competitive with individual LTCI policies. Before finalizing their decision, it is very important for consumers to understand the long-term effects that these premium increases can have. Unfortunately, I see many policyholders who did not understand the ramifications of this kind of inflation protection when they purchased their policy. They sometimes find themselves locked into a policy that is constantly increasing in price and have few options for switching to a more affordable LTCI product due to their age and/or health circumstances.

It is true that automatic inflation protection increases that are built into the premium cost from the inception of the policy will initially be more expensive than a periodic increase offer. But in my opinion, in most circumstances, it is better to lock in your inflation protection costs at an early age, and know that your premiums will remain stable, than take the chance on an ever-increasing premium that may eventually be too much to afford.

Until next time…Duane

Read more about long-term care insurance (LTCI).

I believe activities are crucial to well-being. In the past ten years, research has shown that activities play a large part in preventing the progression of dementia. We also know that socializing prevents loneliness, despair and suicidal thoughts.

For several years I led recreational activities on weekends at a geri-psych hospital. The activities that took place on any particular weekend greatly depended on the patients in the unit at that time. All of the patients there had dementia and behavior disorders that precluded their being able to remain at home until the behavior had been extinguished. Most patients were on the unit between three to four weeks, while the doctors changed their drugs or the dosages. Some were more alert; others were more physically functional. Some returned home; others returned to a nursing home or entered a long-term care facility for the first time after discharge.

There are many activities that are appropriate for people with dementia. The only guideline is to not degrade them by having them do children’s activities. Instead, show your respect by engaging them in pastimes that are similar to children’s activities but suitable for an adult, retaining whatever qualities that make the activity fun. Here are some suggestions for caregivers who have a dementia patient at home.

Puzzles & Games

Try:

• Easy crosswords and word searches that use large type.
• Jigsaw puzzles with very large pieces. The images shouldn’t be child-oriented; try scenery or pictures of animals instead. Floor puzzles are good because they typically have large pieces, and there aren’t too many, which can be discouraging. Work on these on a table so you don’t have to struggle getting off the floor!
• Old favorites like dominoes, card games such as “Go Fish” or “Old Maid” and board games like Candyland and Pollyanna.
• Reminiscing, a board game available through SeniorStore.com, which prompts memories of assorted events and fads from 1939 on.

Photo & Scrapbooking Activities

• Sort photos by topic, subject, type or date. Mix them up after you finish so they can be sorted in a different way next time.
• Assemble a photo collage. Pasting can be fun.
• Make a scrapbook, pasting photos onto the pages and writing notes about the memory beside the photo. You can also use a photo album with plastic sleeves.
• Label old family photos so you’ll have that information later on.
• Reminisce about the focus of the photo.

Housework

• Rake leaves.
• Fold towels.
• Clean windows.
• Cut coupons.

Gardening Activities

• Pull weeds.
• Plant annuals in spring and bulbs in the fall.
• Transplant small plants into larger pots. Have the patient paint pots ahead of time and use these for gifts.

Seasonal Decorating

• String cranberries or popcorn.
• Make door wreaths and window decorations.
• Put up decorations and take them down.

Activities Involving Humor

• Watch or listen to comedy TV shows, movies and old radio shows like “Who’s on first” (Abbott and Costello) and “I Love Lucy.”
• Start a humor notebook or scrapbook.
• Laugh over funny family memories (like the time Mom put frozen rolls on the Thanksgiving table).

Sorting & Organizing Activities

Sort or organize:

• Nails, screws and other hardware.
• Nail polish and lipsticks, sorting by color, brand or on a scale of 1–10, in order of preference.
• Buttons, using muffin tins to sort by color, size or style.
• Coins, according to date, value or place of origin.
• The pantry, arranging cans and jars by size, brand or contents.
• The silverware drawer, rearranging the order of the forks, spoons and knives.
• Playing cards into decks that match, or into suits within a deck, or by numbers. Tupperware by size or color.
• M&Ms, using muffin tins to sort them by color. Choose one color to eat!

Cooking & Activities in the Kitchen

• Make salads, ice cream, Jell-O, pudding (try a hand mixer), no-bake cookies and pies, popcorn balls and other simple recipes.
• Wash fresh produce and put it into bags.
• Grind nuts to use for baking.
• Peel vegetables.
• Copy recipes from magazines onto cards.
• Make a grocery list of items needed for recipes.
• Sort recipes and find pictures to illustrate them.
• Empty the dishwasher (use melamine or plastic dinnerware).
• Set the table.
• Fold or roll silverware into napkins.
• Assemble shish-kabobs with fruit or vegetables (use wooden ones with blunt ends).
• Shell nuts or peas.

Reading Activities

Read out loud or simply look through books and magazines that can lead to discussions. Try:

• Reminisce Magazine.
• Picture books like Bradley Trevor Greive’s The Blue Day Book and Shel Silverstein’s A Light in the Attic and The Giving Tree.
• Old copies of Look or Life magazines.
• The Bible or Bible stories.
• Short story collections, such as Chicken Soup for the Soul.
• Steven Kellogg’sThe Day Jimmy’s Boa ate the Wash and Jimmy’s Boa Bounces Back.
• When I am an Old Woman I Shall Wear Purple, edited by Sandra Martz.
• Dr. Seuss’ You’re Only Old Once: A Book for Obsolete Children.
• John Wagner’s Maxine: Yelling it Like It Is: A Fine Whine with the Queen of Attitude.
• Judith Viorst’s Forever Fifty and Other Negotiations and Suddenly Sixty and Other Shocks of Later Life.

Reminiscing with Memory Books

You can find blank memory books in the baby section of a bookstore. These usually pose questions that will prompt discussion. Here are a few suggestions:

• Grandmother’s Memories: To Her Grandchild by Candy Paul, illustrated by Thomas Kinkade.
• Grandfather Remembers: Memories for my Grandchild by Judith Levy.
• Grandmother’s Scrapbook illustrated by Judy Pelikan.
• Grandmother Remembers Songbook: Heirloom Songs for My Grandchild by Judith Levy and Judy Pelikan.

The list above is not all-inclusive. Hopefully it will give you some ideas for getting started. Think about the kind of activities the patient has always enjoyed. Those are probably the best ones to start with. I’ll close with a few more ideas.

If the care recipient enjoys building things, try assembling model kits of airplanes or cars. A simpler activity could be making strings of paper clips, using different colors and sizes. Patients who have an artistic side may enjoy painting or coloring in one of Dover’s many stained glass coloring books. Musically inclined patients might enjoy singing along to patriotic songs, hymns and old favorites, or playing rhythm band instruments. Did the patient used to enjoy sewing or mending? Offer some pants that need hemming or items of clothing that need buttons sewn on. Remember: people with dementia can still derive enjoyment from activities they have always enjoyed. Give it a try!

Jill Gilbert, our CEO, just finished up her tenth article for McKnight?s Long-term Care News, the eldercare industry?s leading magazine. In her monthly articles, Jill tries to raise awareness and spotlight new and innovative ideas in the eldercare industry by highlighting facilities and people who are outstanding at some aspect of serving the senior population. The articles just keep getting better with discussions on food/menu choices, building a solid care team, Green House projects, Kiwanis International clubs and much more. Not only do all of us at Gilbert Guide like to point out excellence and quality care, but also we hope that by doing so we inspire and set higher standards for eldercare providers across the country.