Chicago's Geriatric Care Manager Center of Excellence – Since 1991 • In Home CaregiverChicago's Geriatric Care Manager Center of Excellence

COVID’s Other Deadly Toll
During this pandemic, over 13,000 more Alzheimer’s and other dementia patients have died than expected from these cognitive disorders,...
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September 22, 2020
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Dementia: We’re Not Post-COVID Yet
If you have a family member or loved one with dementia, this pandemic and its restrictions have been exponentially...
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May 26, 2020
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Distance Caregiving Through a Wall
I’ve written numerous times about distance caregiving, and one of the observations I have offered is that distance is...
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May 19, 2020
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Caregiving During COVID: Four Tips for Reengagement
You may recall that I have recommended limiting your news consumption, because it really does add to our stressed...
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May 12, 2020
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Tips for Distance Caregiving: Up Close and Personal at a Distance
If you think being a caregiver to an older loved one is hard–with all the trips to help them...
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February 4, 2020
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Caregivers and their Medicare?
Yes, you read it right. I am posting this one about what caregivers should know about their Medicare. But...
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September 12, 2013
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In the Caregiver's Words

Recent Client Praise

Excess weight is not healthy and obesity definitely is not healthy, right? When it comes to your older parent or loved one, the answer is a bit more ambiguous. Picture you have been going to the physician with your older mother for a number of years, and mom has been “robust,” BMI 29, but not what would strictly be termed obese. (BMI, or body mass index, is calculated from a person’s height and their weight, and technically 30 or higher is considered obese.) This year, however, mom’s BMI is up to 30, yet she has not gained a pound. So, by the book she is “obese?” Not necessarily…this is part of what is termed the “obesity paradox.” As a person grows older, there is a tendency to lose muscle mass, and it can get replaced by body fat. There is also a tendency to lose height while maintaining a stable weight as in the case with “mom” above. As people age, they may accumulate more “protective weight,” weight that can be a reserve against unintentional weight loss. Among the young obesity is associated with adverse health impact in the form of risk of hypertension, diabetes, heart disease, certain cancers and a negative effect on most organs of the body…and reduced life expectancy. Yet, some older people who are patently obese have dodged these ill effects. These are also part of the “obesity paradox.” The fact is that a lot of their younger cohorts may already have succumbed to disease before they got so old, not unlike the octogenarian who has smoked a pack of cigarettes a day and continues to smoke without any seeming impact on their health. So, should mom lose weight? If it is all weight around the mid-section, weight loss is called for. Appreciate that any weight loss regimen is likely to result in loss of muscle as well as fat and therefore deconditioning. The rule is that weight loss in the 5 to 10 percent of body weight range tends to have positive effects. Also, weight loss that owes to real life style changes such as diet and exercise are positive. This kind of program should also include sufficient intake of protein to be safe. The American College of Sports Medicine also recommends exercise at least twice a week. This exercise should include strengthening exercise and resistance training. They identify what some call “muscle confusion” training which simply means changing up the regimen frequently to encourage a more nimble and flexible gait, balance and core strength. It is also helpful to involve your older loved one’s primary care physician to assure that their medications do not introduce issues of balance or body hydration. But beware of the physician who cautions against exercise for a “person of this age.” Don’t let them discount mom because of birthdays. Get a second opinion. And remember that it ultimately is about quality of life…and a healthy weight. Charlotte Bishop is an Aging Life Care Advisor, Geriatric Care Manager and founder of Creative Care Management, certified professionals who are geriatric advocates, resources, counselors and friends to older adults and their families in metropolitan Chicago. She also is the co-author of How Do I Know You? A Caregiver’s Lifesaver for Dealing with Dementia.
We do a lot of postings on dementia, in no small part because adults rank it as their number one concern, just above running out of money or dying. I have again asked our Vice President, Steve Steiber, Ph.D., to talk to us about what we may not know - but should know - about the evolving science around Alzheimer’s disease and treatment options. Steve has over twenty years of experience as a consultant to the pharmaceutical and biologic industry prior to joining us at Creative Care Management. He reports in this post on what may be a "light at the end of the tunnel we call Alzheimer's disease. What is the first thing you learn when you are admitted to a hospital, and this can be for outpatient or inpatient procedures? ONE SIZE DOES NOT FIT ALL! That applies to Alzheimer’s disease as well. There has been no blockbuster fix for Alzheimer’s, to date, but on closer examination of how people with different genes or with different make-ups respond, scientists are finding they react differently to medications. We already have seen this in cancer treatment, and it is a broad and promising side of medical care called genomics…sometimes called pharmacogenomics when referring to medicines and nutrigenomics for foods or supplements. When physicians look to a person’s specific genes, they can find people who may respond a lot better than someone without those genes. They call it “personalized medicine,” and it is showing some real promise. Let's start with a clinical failure that may actually be something else altogether: tramiprosate (an antiaggregation of amyloid agent). Earlier this year results from a phase 3 clinical trial (this is the final phase for a drug to be up for possible approval by FDA) for tramiprosate showed no appreciable improvement, on average, for Alzheimer’s subjects in the trial versus those on placebo. I said, “On average.” When scientists later looked more closely at the genetic makeup of patients in the trial, they found that those patients with two copies of the APOE4-gene had markedly better results than those with only one or no copies of this gene. Scientists are reassessing how these patients and those with the APOE3 gene respond, especially since these latter are at greater risk for developing Alzheimer’s disease. Worth a second look, for sure. I also mentioned nutraceuticals. In a European study some time ago, there seemed to be some promise for vitamin D as a protective agent against Alzheimer’s. As scientists looked specifically at the patients with two copies of the APOE4 gene and taking vitamin D, they found those patients had better memory scores than those on placebo or without the gene. Vitamin D in the absence of the two gene copies did not seem to do as well. Scientists are also looking more closely at omega-3, what we sometimes refer to as fish oil (it is only in the fish oil, because that is where it is stored after fish eat the algae that contain the omega-3). And there are multiple types of omega-3, two of which are particularly “brain-healthy.” Scientists have a couple challenges here. One, the brain’s absorption of the healthy omega-3 takes a few years, and there also is a difference in the genes I mentioned above. This may take longer to get good evidence, but it also is promising. There also is research into limiting environmental risk for developing Alzheimer’s that is linked to both the APOE4 gene and the presence of pesticides like DDT and its metabolic cousin, DDE. While DDT has been banned in America for some time, its metabolite, DDE, is still around. Preliminary research suggests that it is not just the DDE or just the APOE4 gene, but the presence of both that is associated with higher incidence of Alzheimer’s. While these early findings will not tell you what to ask your physician about diet or medications, it is a cautionary note for all who live in or near agricultural regions. The lesson learned again is that we likely have just begun to tap the genotypic profiles that may lend themselves to less versus more risk or less versus more success. The oncology field has begun to get better and better results in their fights across a number of cancer types by paying attention to genes that can predispose individuals to either greater risks or to better outcomes. It just may be that Alzheimer’s disease can follow the same model. Creative Care Management, certified professionals who are geriatric advocates, resources, counselors and friends to older adults and their families in metropolitan Chicago. Please email your questions to info@creativecaremanagement.com
Within the past two weeks the Food and Drug Administration (FDA) has issued a number of warnings that concern me as a geriatric care manager, and they should concern caregivers and the elders in their charge as well. The FDA has announced new warnings for three different classes of medications, those for pain and inflammation, those that lower cholesterol and those that help treat anemia in some patients. In my next three postings, I am going to tackle each, so that you will have a clearer picture of how to safeguard your own health as well as the health of an elder for whom you may be a caregiver.

I am going to start with a group of drugs commonly called non-steroidal anti-inflammatory drugs or NSAIDs. You would recognize the brand names, Aleeve, Motrin, Advil, or Nuprin as well as their generic names, naproxen or ibuprofen, and a lot of people use them to good effect. Many people use these medications for their arthritis or other acute and chronic pain, and they are available over the counter (OTC) as well as by prescription. You may remember from an earlier posting (Please see: Bad Medicine) that older Americans consume about twice as many prescription medications as younger people and they buy about 40-50% of all the OTC drugs sold.

In an international study titled INVEST, 22,576 people were followed for nearly three years, and the American portion of this large group was followed nearly 8 years. The overall study group included chronic and nonchronic NSAID users as well as people who were on no such medications. Those using NSAIDs were more likely to suffer a non-fatal stroke, a myocardial infarction or heart attack or death from any cause than those not using NSAIDs. In the long term follow-up, researchers found that people who already had a history of either blocked arteries to the heart or high blood pressure were even more at risk for an adverse event that the others.

The researchers suggested that people with high blood pressure or heart disease should look for some other alternative for their aches and pains. Fortunately there are some alternatives for pain. I recommend a sit-down session with the patient’s primary care physician to do a medication audit. As a geriatric care managere, we can do these audits, but only your physician can prescribe medications. If the doctor is not aware of the OTC pain meds a patient is on, then it is hard to make a good decision. The other obvious right steps would be diet and exercise. For high blood pressure and for arterial blockage, minimizing bad cholesterol in the diet and reducing weight are real winners. As always, consult with a physician before embarking on any exercise or diet program.

Charlotte Bishop is a Geriatric Care Manager and founder of Creative Case Management, certified professionals who are geriatric advocates, resources, counselors and friends to older adults and their families throughout metropolitan Chicago. Please email your questions to Charlotte Bishop.
If you will be heading home for any of these seasonal holidays you will find that it can be a wonderful trip back in time as you revisit your own family history in the context of your mom’s or dad’s house. But when you visit, take a closer look at how safe that house may still be for your older parent living there. Some parts of the home interior landscape may be just like you remember them, but they may now pose hazards to your older parents.

    Start with electrical fixtures. Check for where the cords to lamps or telephones and other household appliances are. If they are in the flow of traffic, consider arranging furniture differently. Also, remember that extension cords are really only meant for temporary use, so it is a good idea to move fixtures to be closer to outlets. If you must use an extension cord, place it against a wall to reduce the trip hazard. If there are electrical cords under furniture, check for wear on the insulation to avoid fire risks. Cords under carpeting or rugs also can wear to the point that the floor covering becomes a fire hazard. And, of course, frayed or cracked cords should be replaced. Finally, check to see that all outlets have secure cover plates so that no wires are exposed. Do the hands-on test as well to be certain no outlet is unusually warm to the touch, a sign of potential overloads and therefore a fire risk.

    The Consumer Product Safety Commission has estimated that thousands of people 65 years and older each year are treated in hospital emergency rooms for falls associated with rugs or floor runners. Older adults have less agility and some shuffle as they walk making the trip hazard even greater, so remove rugs that cannot be securely attached to the floor. It is easy to use double-sided adhesive tape to secure rugs or use rubber matting under the rug cut to size is an alternative.

    In addition to replacing batteries in smoke detectors, make sure there are enough detectors placed throughout the house. Especially if one of your older parents has any difficulties with hearing, you will want to have multiple detectors, and they typically come with instructions on where they optimally should be placed in the house. Adding a carbon monoxide detector also is important if there are any fuel-burning appliances in the home. Even homes with electric kitchen appliances may have gas-burning heating units or water heaters.

Because accidents can still happen despite all these preventive measures, make sure emergency numbers are close to every telephone in the house. Include the local Poison Control Center along with a trusted neighbor’s number and your own family ICE (in case of emergency) contact. Write these telephone numbers in large print and tape conspicuously near each land line. Check also that phones and contact numbers are accessible to your parent in the event that an accident leaves them unable to stand.

    Charlotte Bishop is a Geriatric Care Manager and founder of Creative Case Management, certified professionals who are geriatric advocates, resources, counselors and friends to older adults and their families in metropolitan Chicago. Please email your questions to Charlotte Bishop.
I have asked our vice president for senior services, Steve Steiber, Ph.D. to share a guest posting about the recent news on prescribing combination medications including acetaminophen. Dr. Steiber has two decades experience in pharmaceutical and medical device consulting prior to joining CCM about 8 years ago. He reports: Let me start by saying very unequivocally that when taken as directed, Tylenol (acetaminophen) is a safe and effective analgesic. That said, the US Food and Drug Administration (FDA) has recently asked healthcare professionals to stop prescribing prescription pain relievers that contain more than 325 mg of acetaminophen per dose. The reason is very simply the potential for liver toxicity. This is not news. Medical providers have known for some time that acetaminophen in excess of 3,000 mgs a day can shut down the liver; some even place the bar lower at closer to 2,000 mgs. This latter threshold may be most appropriate for older adults as their systems do not process chemicals out of their bodies as readily as younger bodies do. The most recent attention from the FDA is for the number of what are called combination medications - those that contain two or more active ingredients. Acetaminophen is one of the more common additives to other pain medications, cold and flu medications or allergy medicine. In fact, - which contain Tylenol in addition to something else. It is estimated that there are in excess of 70 medications that contain some amount of Tylenol in combination with something else. FDA has set the dose limit of acetaminophen very simply because there seems to be no evidence that doses in excess of 325 mgs does any more good than the lesser dose. Although acetaminophen is classified along with drugs like naproxen or ibuprofen as non-steroidal anti-inflammatory drugs (NSAIDs), unlike these other two, it is a very weak anti-inflammatory. In short, more is not necessarily more effective. FDA's action will have the most direct impact on some of the heavy hitters among pain medications, those also containing an opioid like codeine, hydrocodone or oxycodone. In some of these mixtures, there is as much as a 750 mg dose of acetaminophen. According to the FDA: "There are no available data to show that taking more than 325 mg of acetaminophen per dosage unit provides additional benefit that outweighs the added risks for liver injury. Further, limiting the amount of acetaminophen per dosage unit will reduce the risk of severe liver injury from inadvertent acetaminophen overdose, which can lead to liver failure, liver transplant, and death." FDA had asked that drug manufacturers comply with this request by January 14 of this year, but it would still be advisable if you are a caregiver to an older loved one on one of the affected medications that you read the label and the doctor's recommended dose. This will be particularly true of over the counter (OTC) medicines that contain acetaminophen as they are not covered by this action. Please let Steve know if you have any questions about drugs, their side effects or the unique medical challenges faced by older adults or others with special needs. Please email to: ssteiber@creativecaremanagement.com
Most of us have become familiar with generic drugs. We now have a new category in your medicine cabinet called “biosimilars,” so I have again asked our Vice President, Steve Steiber, Ph.D., to talk to us about what we may not know - but should know if you are a caregiver to an older loved one - about the evolving federal rules and science around biologic medicines and the new medicines who are enough like them to get FDA approval. Steve has over twenty years of experience as a consultant to the pharmaceutical and biologic industry prior to joining us at Creative Care Management: We all have heard of some of the (mostly) injectable medicines that have changed the lives of people with rheumatoid arthritis, Crohn’s disease, psoriatic arthritis and some other conditions that are part of a larger category called autoimmune diseases. They have been around for about twenty years and have become names many of us know from television and magazine ads. We also mostly know what a generic medicine is. It is the same chemical molecule as one that a drug company brought to market with a “brand name,” but it is manufactured by another company after that brand drug’s period of patent exclusivity expired. All drugs discovered by a company can be patented for 20 years so that no one can make and sell the same drug until that patent expires. Companies apply for patent protection well before they go to FDA for approval, so they do not have a full 20 years alone in the market following FDA approval. For instance, once Aleve’s patent expired, you had other companies flooding the market with naproxen sodium (the generic name of Aleve). And once Motrin’s patient expired you got ibuprofen, and Tylenol gave way to acetaminophen, and so on. Well, one of the provisions of the Affordable Care Act (ACA) was to change the rules for biologics to be like that process. Before ACA changed those rules, any medicine patterned after one of those approved biologics like Humira, Remicade, Cimzia and others had to go through a process just like a new medicine. Now, like the generics, a medicine can apply to be a biosimilar to a brand medicine simply by proving it is as good as that medicine. Hence, the name biosimilar. Don’t ask me why they couldn’t call it “generic,” but it amounts to pretty much the same thing. So, if you are a caregiver to an older loved one on a biologic, you may soon have a cheaper alternative available. Generics and biosimilars inevitably will be cheaper than the brands they are like. It also means that in most states the pharmacist can substitute the biosimilar for the brand medicine if you agree … even if your physician writes the branded name on the prescription slip. Do your research so that you know the clinical evidence on the new biosimilars as you make that decision at the pharmacy or in a conversation with your care receiver’s doctor. Think of it as getting a BMW-performing car without the logo…and without the price tag. But ask your physician for their thoughts. Charlotte Bishop is a Geriatric Care Manager and founder of Creative Care Management, certified professionals who are geriatric advocates, resources, counselors and friends to older adults and their families in metropolitan Chicago. Please email your questions to info@creativecaremanagement.com.