End of Life Planning For Your Pets

By: Lisa Bayer, J.D., CCM

Over the years as a geriatric care manager, I have been in hundreds of client’s homes. I also think that I have seen everything! I recently encountered a situation that truly threw me for a loop.

I was engaged by the legal guardian of a client who lives out of state to be her “boots on the ground” with respect to her loved one, Margaret. Margaret had a catastrophic event and suffered a TBI (traumatic brain injury) which requires skilled, nursing home level care. Before the TBI she was living independently in her own home with her dogs. She had never married, has no children, and has no other local involved family members.

One of my responsibilities was to help coordinate the emptying and selling of her home. The (living) dogs were surrendered to a local rescue but nothing prepared me for the 16 boxes of cremated pet remains that we found all over the home.

Part of the issue is that Margaret’s sister could not relate and would have thrown them in the trash if it were up to her. However, as the court-appointed legal guardian she was required to respect Margaret’s wishes, known or unknown, to the best of her ability. So, what to do?

Margaret’s sister had engaged an amazing realtor who partnered with me throughout the process to find solutions to each scenario that we encountered. And there were many!! In this case, we contacted local pet cemeteries to inquire about process and cost for burial.  One of them was sympathetic and worked with us to keep the cost down by offering to combine plots of more than one pet. This was the best way that the guardian could think of to respect what Margaret may have done, or directed, if she had been able to.

Personally, I learned from this experience something that I will bring to my practice in the future. While many wills address what happens to pets after a person passes, most power of attorney documents (especially older ones) that I have seen do not always address how the agent should care for the living pet(s). And I have never EVER seen one that addresses how to treat pet remains when your loved one loses capacity and cannot speak for themselves. I always ask clients as part of onboarding to share their planning documents with me. As a trained attorney, I am able to make meaningful suggestions when it comes to any updates to make sure that the documents will work if needed. After this recent experience I will be more cognizant of not just living pets but how to handle their remains if a client is no longer able to do so him or herself.

PCR is Not Just a Covid test; A 21st Century Approach to Diagnosing and Treating Urinary Tract Infections

Written by: Lisa Bayer, J.D., CCM

Recently, I had the pleasure and privilege of sitting down with Dr. Joseph DiTrolio, and Ms. Pilar Vega, Senior Director of Business Development with Premier Medical Laboratory. By way of history, Ms. Vega and I were speaking one day and she alluded to a qPCR (Quantitative Polymerase Chain Reaction) test that her lab offers patients in multiple care settings. Ms. Vega explained that the results of this type of test is typically available within 24 hours and allows for more pinpoint targeted treatment, or in some cases non-treatment, than the traditional “scorched earth” approach of prescribing a generic antibiotic for urinary tract infections (“UTI”) while waiting 4-5 days for the culture results only to find out that a patient does not have a UTI or the prescribed antibiotic is the wrong one.

Over the past two (pandemic) years we have all become well accustomed to the term “PCR.” I for one did not realize that it is not a Covid-specific test but rather stands for “polymerase chain reaction” which is a type of testing that looks at a pathogen’s DNA profile to identify the organism(s). The qPCR can also detect the genetic makeup (the DNA or genes) of the pathogen to prevent and avoid antibiotic resistance. As a geriatric care manager, most, if not all, of my clients have suffered from at least one, usually multiple, UTIs. I was curious and so Ms. Vega graciously set up a meeting so that I could ask Dr. DiTrolio questions and learn more about this approach.

I asked Dr. DiTrolio to please explain why the qPCR test is preferable to the traditional urine culture and why, if it is not better, it is not the standard of care. At the outset, Dr. DiTrolio explained that 50% of people who present with a possible UTI do not actually have one. Yet, physicians often prescribe antibiotics before testing as the traditional culture takes 3-7 days to get back and they do not want the patient to have to wait. And, while Dr. DiTrolio was too polite to say it outright, I inferred that to do the less traditional qPCR while still a urine collection, may involve a bit more effort to arrange to have the right lab pick up the samples. Meaning, some providers do not take the time or make the effort to become educated and instead rely on 100-year-old protocols. The old “if it ain’t broke why fix it” adage. Yet, in the end it is the patient, our health systems and our children and grandchildren who suffer if we mistreat patients and create drug-resistant organisms in the process.

As Dr. DiTrolio explained, the longer a urine specimen is out of the body, the greater the chance that the results will be tainted. Furthermore, if two or more strains are present, using the traditional method of waiting for a culture gives the “dominant” bacteria strain a chance to destroy or mask the less dominant strain(s). This does not mean that the bacteria are all gone—just that it was not picked up on the traditional culture. And so, we see occurrence or reoccurrence of bacteria that were present but not picked up and therefore not treated properly the first time around.

The qPCR test is covered by Medicare so it is not a payor or reimbursement issue. In fact, by procuring a reliable, quick test it can actually save money and produce better outcomes. This is because if the antibiotic is wrong then the patient does not only not get better, but he/she will need another course of treatment. Overuse and inappropriate use of antibiotics can lead to additional morbidities such as Cdiff recurrence, gastrointestinal disturbances and yeast infections. A severe, untreated UTI in a patient with multiple health problems is also more likely to end up in the hospital. In the worst case it can lead to death.   

In sum, it is important for caregivers, patients and their advocates, such as geriatric care managers, to ask questions of physicians and other providers and to insist on meaningful explanations and answers so that the care recipient has the opportunity to make informed and educated decisions on his or her care.

---

*Joseph DiTrolio, MD, is Urologist in private practice in Roseland, NJ. He serves as Professor and Chairman of the Board for the New Jersey Medical School Alumni Association, his alma mater. He holds numerous patents and has authored and presented on hundreds of papers and articles all over the world. Dr. DiTrolio is committed to the care and support of our beloved veterans. Since graduating medical school in 1979 he has been affiliated with the East Orange Veterans Administration focusing on injuries and illnesses related to the urological system. 

*Pilar Vega’s background is in business and the life sciences.  She has over twenty years of experience in healthcare with a focus on diagnostics, pharmaceuticals and medical equipment. branches of the industry.  Pilar is a committed advocate of optimal care for every patient regardless of means or life circumstance.

Hope For a Sharper Mind

By Guest Blogger: Lisa Feiner

Until recently, it was thought that we were born with all the brain cells we would ever have, and they were slowly lost over time as we aged. Research shows, however, that the brain is neuroplastic and neurogenerative, able to continue learning and growing new connections. When the brain receives the right nutrition, enough mental stimulation, nourishing friendships, exercise, and sound sleep, and is also protected from trauma, prolonged stress, toxins and infection, it thrives. And we now have a good idea about how to keep it thriving throughout our lifespans.

According to the CDC, dementia is not an inevitable part of aging[1], and yet Alzheimer’s and other types of dementia cases continue to rise, even in younger age groups. A recent Blue Cross Blue Shield study reported a 373% increase in diagnoses of early onset dementia and Alzheimer’s disease among 30 to 44 year-olds, and an overall 200% increase in those aged 30-64.[2] How can this be? The nonprofit, Sharp Again Naturally (SAN), has identified more than 10 reasons our cognition can start to falter, and the seeds are often sown decades before symptoms appear. Reasons may include poor diet, a sedentary lifestyle, low hormone levels, heavy metals, prescription drugs, emotional and physical trauma, and more.

Some people, including doctors, will tell patients that nothing can be done to treat Alzheimer’s disease or mild cognitive impairment, and to go home and get their affairs in order. A prescription may be offered to help slow the disease for a few months. There is more that we can do. There are now protocols that for many people can preserve and/or restore partial, if not full, cognition. Studies are ongoing and several books have been written about this new multi-modal approach: instead of one drug, a combination of lifestyle changes, supplements, and other interventions are used.

Family members, close friends, co-workers and even neighbors are often in the best position to notice when someone is having memory issues. For example, they see that bills aren’t being paid or past experiences and conversations are not being recalled. There may be a change in personal habits, such as more frequent purchases from a home shopping network or lists being posted throughout the home.  Memory problems usually appear slowly and worsen gradually, but often the person him or herself starts to realize that they are having frequent lapses. It is at this stage that interventions can be most helpful.

A professional case manager, such as LMR Elder Care, works with families and individuals and often sees people who are at various stages along the dementia journey. In fact, it is not uncommon for the caregiver of someone with dementia to begin to suffer memory issues too. We know that caregivers who are caring for someone with dementia are six times more likely to develop dementia themselves.[3] The objective professional is in a unique position to holistically evaluate what is happening and refer the family to appropriate resources. That is why it’s essential for all of us to understand that memory loss should be addressed as it may be treatable, and to seek help as early as possible. We all deserve to live a full life with our minds intact.

Lisa Feiner, MBA, M.Ed. is a Board Certified Health and Wellness Coach and a founder of Sharp Again Naturally. SAN educates people about the causes of memory loss and offers tools to preserve brain health (sharpagain.org).

Citations:

[1] www.cdc.gov/aging/publications/features/dementia-not-normal-aging.html

[2] https://www.bcbs.com/the-health-of-america/reports/early-onset-dementia-alzheimers-disease-affecting-younger-american-adults

[3] https://www.sciencenews.org/article/caring-spouse-dementia-leaves-caregiver-risk

Having “The Talk” With Mom and Dad

By Guest blogger: Michael Daniels

It’s funny how life has a way of going full circle.  When I was a child, mom and dad sat me down for a talk about “the birds and the bees.” Fortunately, my parents and I survived that experience relatively unscathed.  Fast forward 30 years.  I’m in my 40s while mom and dad are in their 70s.  It was time for another “talk.” This one would be as awkward as when I was young.  However, this would likewise be a critical conversation – “Mom and dad, how do you manage your personal finances and what should I (your son) know about them?”

At first, my parents were a bit hesitant to openly respond to my questions.  They know that financial services have been my profession for over a decade and that I have these conversations with clients all the time.  However, they were uncomfortable sharing this very personal information, which is completely understandable as I am their son, not their attorney or financial advisor. Rather than push them to disclose sensitive information, I educated them as to why it was important to share.  After a brief, yet focused, conversation, I left them with important reasons to consider sharing their personal finances with me, their adult son. These include:

• If something happened to one or both of you, how would I know what accounts you have or where your important documents are stored?  How would I “pick up the pieces” and manage your affairs?

• Are you prepared to cover retirement and potential long-term care expenses?  If not, what is “Plan B”?

• How would you like your house, your property, and your possessions to be distributed someday?

I wish that I could share that immediately following “the talk” my parents provided me with all of the information I would need to handle their affairs. On the bright side, it did begin a series of necessary conversations.  Eventually, my parents not only got their estate plan documents executed, they also explained to me how their finances are set-up and where important documents (wills, powers of attorney, statements, etc.) are located.

To all the parents and adult children out there that are avoiding “the talk” because it may be uncomfortable, I urge you to consider making an attempt sooner rather than later.  Dealing with the fallout from not knowing critical information about household finances is much more difficult to handle.

————————————————————————————————-

About Michael:

Michael is Senior Financial Advisor at Financial Focus Group. He is responsible for helping clients make strategic decisions in the areas of risk management, wealth management, tax strategies and estate planning strategies. Office Phone: 201-626-6688 * Email: mdaniels@ffgus.com

Michael Daniels is a Registered Representative and Investment Advisor Representative of Securian Financial Services. Securities and Investment Advisory services offered through Securian Financial Services Inc. member FINRA/SIPC. Financial Focus Group is independently owned and operated. 95 Christopher Columbus Drive Floor 12A Jersey City, NJ 07302 TN:3564400/DOFU:5/2021

Financial Professionals do not provide specific tax/legal advice and this information should not be considered as such.  You should always consult your tax/legal advisor regarding your own specific tax/legal situation.

The Importance of "Mind Sports” Like Chess

By Guest Blogger: Evan Rabin

During the COVID-19 pandemic, thousands of seniors around the world have been and remain isolated. For over a year, they have been unable to socialize with family and friends. While progress has been made ( I have personally received my second vaccine), most people I speak with do not anticipate the world returning to “normal” any time soon.  

Mentally challenging games, such as chess, can help older adults, or anyone for that matter, manage the stressors that the pandemic has thrust upon us. There are virtual platforms for learning and playing chess with real live people which allows for safe socialization. 

In addition to relieving stress and providing for social engagement, there are studies that show that “cognitively stimulating activities,” such as chess, which require a lot of brain power, can help improve a person’s memory and slow the progression of Alzheimer’s Disease and other dementias. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6617066/  

About Evan:

Evan Rabin, a National Chess Master himself, is the founder and CEO of Premier Chess. If you would like to learn more about the social and health-related benefits of chess please contact Evan at Evan@PremierChess.com. Premier Chess (https://premierchess.com/) offers online and in-person individual lessons and group classes. Premier Chess partners with companies and non-profit organizations to help realize Evan’s dream that anybody who wants to play chess anywhere in the world should be able to do so.

Care Managers and the Importance of Objectivity

by Lisa Bayer, J.D., CCM

Heidi and I founded LMR Elder Care, LLC with the mission that “care management” would remain our core focus. For more than 15 years we have held true to that mission. 

Every new client of LMR Elder Care receives a disclaimer when they onboard with us. This disclaimer is as much for our clients’ protection as it is for ours. We want our clients to know that, with the help of their families, friends and trusted advisors, we will hold their hands and guide them to make informed elder care plans and decisions. But we also want our clients to know that we will always strive toward “the best interest of the client” and that we will not substitute our judgment for that of our clients or of their authorized agents. We believe in a collaborative approach to elder care and we encourage our clients to lean on all of their trusted professional and paraprofessional advisors.

One core pillar of our business is that we do not accept referral fees. That means that when we include an organization or service in our directory or recommend a provider to a client, it is because we believe that provider will provide a necessary service.  At the heart of what we do is protecting our clients. While we do our best to promote long-term care planning and healthy aging, the reality is that most clients hire us when there is already an actual (or near) crisis. It is important to us that families are not taken advantage of when they are at their most vulnerable. 

The elder care space has evolved a lot over the last 15 years since we started our practice. In this regard some home health care agencies have started offering fee-for service private pay care management services. In this instance, a client is paying the agency for care management and the client is also paying for home health care. This arrangement creates the potential of a “dual relationship” for the care manager as he or she is duty bound to the client and to the employer who is both providing the services and who is paying the care manager’s salary. With a dual relationship the boundaries are blurred and objectivity can become diluted.

Dual relationships can also rise to a true conflict of interest between the care manager and his or her clients. For example, consider a company that provides both fee-for-service private pay care management AND home health care services.  Would the geriatric care manager even be allowed by his/her employer to recommend a more appropriate agency or caregiver? What happens if the home health aide is not performing his or her job adequately or the client simply does not like the caregiver? Simply put, without the checks and balances of independent providers comes the potential for exploitation and abuse. We have seen and heard everything over the years; home health aides offering sexual favors for extra cash, dementia clients abandoned overnight when they were supposed to be under watch, and theft of family valuables. Unfortunately, anything can happen at any time, but the opportunity to correct and protect is diminished when “Peter is Paul” and “Paul is Peter”.

When working with older adults and persons living with disabling conditions, it is important to  insist on transparency, ask necessary questions, and perform reasonable due diligence on all service providers. At LMR Elder Care our number one priority is what is in the best interest of our clients. We advocate for you and only for you.

I’m Sorry, But What Did You Say???

By: Lisa Bayer, J.D., CCM

Recently, I met with Dr. Rhee Rosenman-Nesson, Au.D., CCC-A to learn more about the importance of good hearing health for everyone, but particularly older adults who may be showing signs of dementia and other age-related medical and psychological conditions. Dr. Rosenman-Nesson is the owner and founder of Hearing Doctors of New Jersey with an office in Livingston, New Jersey.

According to Dr. Rosenman-Nesson, poor hearing can increase the risk of:

·       Falls

·       Cognitive Impairment (such as Alzheimer’s disease and other dementias)

·       Social Isolation

·       Depression

Poor hearing has been associated with an increased risk of falling. A person with low hearing may miss auditory cues (such as a pet underfoot). In addition, it takes a lot of mental energy, particularly for a person experiencing hearing loss who is trying to compensate using their other senses, thereby leaving less bandwith for concentration on balance and posture.

According to Dr. Rosenman-Nesson, hearing loss can lead to an increased risk or earlier onset of Alzheimer’s disease and other dementias. She explained that when a person is deficient in one sense (hearing) they use their other senses such as watching a person’s lips while they speak, to interpret and compensate. If the hearing part of the brain remains unused, it begins to atrophy. “Use it or lose,” explains Dr. Rosenman-Nesson.

Hearing loss can also lead to social isolation and depression. Dr. Rosenman-Nesson explained that when a person is constantly asking people to repeat what they are saying they tend to, at some point, give up and sit quietly at the dinner table or alone at a party. Eventually, they may decline social invitations and avoid activities altogether leading to social isolation and consequent depression. 

Dr. Rosenman-Nesson explained that there are many new and innovative solutions for helping her patients improve hearing and that it is not “one size fits all.” For example, for active adults who do not want their hearing aid to show (if they cannot cover it by growing their hair longer) there are small, clear-colored devices that are barely noticeable. What I was most interested in are the new products that make it easier for caregivers to assist my clients with their hearing aids. For example, they make larger, more manageable devices that are harder to lose and that can be clipped to a person’s clothing if they inadvertently take them out. They also make devices that can be tracked by GPS with a smartphone.

LMR Elder Care and Hearing Doctors of New Jersey’s team approach helps to keep our clients and patients connected and living healthy, productive lives.

To learn more about Hearing Doctors of New Jersey please visit https://hearingdoctorsofnj.com/ or call Dr. Rosenman-Nesson’s office at 973.577.4100.  

The Alphabet Soup of Medicare

by Lisa Bayer, J.D., CCM

It is open enrollment time for Medicare supplemental plans and anyone who has tried to navigate the process is faced with a myriad of choices and terminology. There’s Medicare A, B, C and D. Part A is your inpatient insurance, Part B is your outpatient insurance and Part D is your prescription drug coverage. Part C is sort of a combination of A, B and D and these plans are known as “Medicare Advantage” plans.

If you do go the traditional Medicare route and you are considering a Medigap policy (a supplemental plan that helps to fill in Medicare coverage gaps) you could be looking at another mouthful of letters! For the heck of it I put in our zip code and the Medigap plans available in LMR Elder Care’s area, 07039, include A, B, C, D, F, G, K, L, M and N. And if that is not enough would I want a high deductible or “regular” Medicap plan? So how does one decide? To start, make a list of your medications and medical providers. Next, enter your information at www.Medicare.gov, access a state SHIP counselor (a volunteer trained to provide objective Medicare benefit counseling - https://www.state.nj.us/humanservices/doas/services/ship/ - in New Jersey), or get in touch with a private insurance representative that can help you select a plan at no fee to the Medicare beneficiary.

It is important to note that if you are not subject to a special enrollment period this is the only time of year that you will have the opportunity to review, and possibly decide to change, your supplemental insurance and prescription drug coverage. As Eric Cohen, Managing Director of Benefit Quest, Inc points out, “It’s important to sign up at the right time if you want to make any changes or adjustments to your health coverage or your prescription drugs.” For 2021 this review period takes place from October 15 through December 7, 2020.