Fitness and Strength

[The chair on the left is for chair yoga. It is designed to keep you sitting up tall and straight. It works. It is the most uncomfortable thing I have ever sat on other than a bicycle seat. I no longer have the padding down there to be comfortable. We play tai chi in the stuffed chair with arm rests. Some people almost go to sleep. Similar chairs are used in the dining and activity areas.]

The fitness program at Provision Living at Columbia has now developed into physical therapy, tai chi, chair yoga, and strength training in free daily classes and open gym with an instructor. Individual workouts can be done in our apartments and the gym after necessary instruction. (The staff from the paid physical therapy and occupational therapy conduct part of these classes.)

I have learned some common rules that make exercising safe and productive over the past three years. There is no need to waste time and money on activities that are not productive and can even be harmful.

This all started for me on an early spring day in Walmart before we were gardening. I squatted down to see something on a bottom shelf and could not get back up! I called for my wife to push the cart over so I could climb up on it. I then invented an exercise that mimicked standing up from the floor with the aid of a support. In just a couple of weeks, I could stand again without the support. Walking a mile a day seemed to have no effect here; different muscle groups.

Physical therapy classes practice muscle groups needed in common body movements with an emphasis on fall prevention.

Tai chi and yoga are stretching exercises that start with your present abilities. If an activity hurts, stop. Don’t make matters worse. Hold the position for your body to “catch up” (stop hurting) and then relax.

Strength training is a scaled down version of the “grunt and grown” we all associate with gym exercises. Now the emphasis is on maximizing strength rather than growing muscle mass (slow relaxation rather than maximum effort).

All four approaches to fitness involve stretching selected muscle groups. Physical therapy practices common body movement. Tai chi and yoga can select one muscle group at a time including those we rarely use.

It was with tai chi and yoga that I discovered muscle groups that were the cause of my severe back pains. Then stretch to the maximum or until it hurts. Stop for a few seconds. Relax. Repeat 3-5 times. Go to the next exercise.

[The key to success is to fully stretch without hurting, pause several seconds, and relax. Just gliding through the motions does not work.]

We do not learn to play the piano by repeating the same 4 notes endlessly. We learn by playing music. Tai chi and yoga have hundreds of exercises imbedded in stories (music) with strange sounding and impossible to remember names.

It still amazes me how effortlessly these movements can produce the effects they do. I can now do most of these (stretch) until my muscles tremble without hurting. In the past week my back pain has been reduced to a numb spot on the lower right side. That is how this back pain event started about five years ago.

Strength training should increase my strength and reduce the muscle trembling. Residential care eliminates the exercise found in normal daily household and gardening activities. Periodic practice in open gym and in our apartments should replace these activities with an activity that also fills time for many people.

Medicare Drug Charges

Each Medicare Plan is also associated with a collection of pharmacies. Each pharmacy must find drug suppliers. Plans can rank the same drug in different tiers, related to generic or brand name. Drug suppliers can ship in different amounts. The same drug in the same amount can have a different cost.

Annual Premium and Drug Cost

I charted 2017 drug costs from eleven pharmacies, in area code 65203, used by the three HMOs in Boone County, MO, for two drugs I use.  The annual premium and drug costs range from zero for Essence to $600 for Coventry and AARP.

Full Cost

The full cost for each plan (Medicare and you) also varies. Coventry moves the most money and ARRP the least. Essence is about the average of the other two. 

The portion you pay is fascinating.

Portion You Pay

You pay zero with Essence as Medicare pays the entire amount. AARP has you paying about half the costs. However half the cost of a lower full cost rate ends up pricing AARP and Coventry annual premium and drug costs the same.

Essence is performing the same service as the other two with no premium charge. Shipping an unrestricted amount of pills rather than a 30-day supply reduces shipping and handling costs (but reduces the option for a profit factor).

A savings of about $600 is made by using an in-network pharmacy (CVS Pharmacy and Schnucks). The remaining variation must be in the deals between Medicare, drug plans, drug suppliers, and pharmacies.

Medicare.gov must be searched each year to find the pricing for the next year for plans and for drugs. Users can pick the best plan(s) and hope their drugs will be included. Medicare.gov puts all of this information in one spot. 

Again, print out the range of plans and pharmacies you may use. Then find an agent or broker to pick the best one for you for next year. The old time habit of picking a company for life is no more. It may not offer the plan you want for next year. Medicare.gov works well after you become familiar with using it and you get all the needed information in hand.

Medicare Annual Election Period

A Medicare broker, Vice President of Senior Benefit Services (SBS) located here in Columbia, MO., presented a meaningful program at Provision Living last week. I am writing this so I do not have to remember how to do a complete review of Medicare policies each year. It must be done each year.

Once again knowledge is power and money. We went from a $11,000 per year Medicare insurance premium to zero a year ago (see 14 March 2016 post). We planned to stay with the same company in 2017, but cost is just one item. There are a number of others that can all change from year to year, including the company dropping coverage in our county. It would be nice to have a simple way of making this annual review.

Google yielded nothing I was looking for about brokers. I eventually found eHealth Medicare that is close to Medicare.gov but it did not list our Boone county 5-star HMO. Healthmarkets seems to be an incomplete version of Medicare.gov but also sells policies.

Medicare.gov lists all the companies, plans, and prices, but does not sell anything. Drug comparisons are flaky unless the compared companies use the same drug providers. Premiums, maximum out-of-pocket expenses, and drug expenses remain the main differences for residential care residents [catastrophic expenses].

Essence Health Care, Boone County HMO, for example, has zero premiums, zero drug expenses and a maximum out-of-pocket expense of $2,900. Is this the best deal for 2017? It is the only five star company in Missouri. It provides the same services as the company charging $11,000/yr, in network, in 2015.

My brother’s insurance company hired a broker to optimize its services. Insurance companies are willing to pay experienced people to find the best fit in the current Medicare market.

In summary, a real Medicare broker (licensed to represent a full range of options) costs you nothing to review the year’s offerings. Print out a list of companies and policies in your county from Medicare.gov; so you know the full range of options.

Offering plan F but not plan G, and omitting HMOs removes low cost options. Most companies in Missouri pay a top commission of $443 per each new advantage policy sold (CMS.gov, Agent Broker Compensation). A commission is earned only if you change companies or policies. Check with your current agent.

We must do this every year as Medicare is as much a political process as a rational business process. Pick bottom dollar premiums; lowest maximum out-of-pocket expense; all doctors, hospital and drugs in network; and top star rating.

There is no guarantee that your 2016 policy will be offered in 2017. My brother’s broker split their coverage between two companies to obtain the best price for prescriptions.

Fitness Room to Gym

It is October 12 with a cold morning rain. Lawn, garden and flowerbeds will soon be asleep. We totally missed working in them this summer. This has not been a problem for my wife. It is a major problem for me.

I now weight about 5 pounds more than when I graduated from high school. And that 5 pounds is right around the belt line. I can still walk several miles without a problem except my legs get tired. There is in general, a lack of strength I formerly had.

As an example, much emphasis was placed on getting up from a fall. I questioned how we get down to the floor in the first place. So I practiced, as I learned to do with home exercises that mimic the real thing. I designed a fall like my wife and I often have working in the flowerbeds. We tip over forwards, to the side, and backwards when we loose our balance or get a foot entangled in something.

I squatted down, reached back to catch myself, and hit my head on the carpeted floor. My feet were straight above me. Wamp, my hips hit the floor. This was not a soft roll as in the garden. I learned two things: I had lost a surprising amount of strength and I could get hurt if I did not do something about it.

Original Fitness Room with
 Treadmill and Bicycle Removed

The originally designed exercise room at Provision Living at Columbia held a treadmill across the window and a bicycle with a TV on the wall to the left side of the space. I would label the room as standard issue in residential care design for assisted living (marketing requires an exercise space). The vending machine is the first item to convert the space into a community store.

Theater Set for Exercise Class

After a few months the stretching exercise classes moved to the chapel and the theater. Both assisted living and memory care residents shared the same sessions. The lower floor memory care unit we live in is now full. The two groups of residents now have independent exercise sessions more fit to their needs.

Theater and Former Chapel

The exercise program for assisted living, developed into physical therapy, tai chi, and chair yoga, in the theater. Strength training was added when the gym was installed in the chapel. “Stretching exercise” has now been reduced to “exercise”.

Right Wall

Left Wall

Back Wall and Storage

Open house for the gym was yesterday. An original token offering has now developed into a full, individualized, exercise program with emphasis on learning to do, within each person’s ability, exercises that can be done in our apartments as well as during open gym time.

The new director of all the exercise programs introduced himself as, “the guy who makes exercise fun”. If the classes were not fun, no one would come back.

I of course am already a true believer. I have gone from barely able to walk and intense pain, to walking normally upright with little or no pain. My shoulders and hips are both free moving and entirely pain free for the first time in several years. And most of this was done with stretching exercises under the direction of observant and experienced instructors, who provided immediate feedback on doing things correctly, to get the maximum benefit [and avoid damaging effects].

Fitness room to stretching exercises to exercise to gym show a mixture of views of the same thing and of different things. Most people here have a totally inaccurate view of the exercise program that is currently envisioned with the addition of the gym.

I did when we arrived. The mental aspect is as important as the physical. It is 4:25 pm and my back is pain free after chair yoga this afternoon (1:30) and a 1.5 mile walk out to Twin Lakes on the County [Poor] House Trail yesterday. 

Visit or Visitation

We visit one another in our homes. We make a visitation at care facilities. There is something different between the two. On a scale of 10 to 1 we progress from fully alive, healthy, and happy to only a spent form.

When visitations occur in our homes they have house rules just as in care facilities. The first party is doing great, the second not so great, from one point of view. In reality, both may be doing great at their individual stage of life.

I have struggled nine months trying to bring the two views together without grief and tears. I got six invites emailed this week. What can visitors expect? What helpful results can come from visits to all three parties?

In the past 24 hours my wife has lived in a wide range of worlds. From only responding to a residential assistant (RA); to periods of agitated keepsake sorting; to going to bed on her own; to being lost, and for a moment not wanting to stay, until we returned to our apartment and she saw her keepsakes.

My older brother and his wife visit us each Sunday afternoon. We have worked out a system. We meet in the activity area. If my wife is fully engaged in something she may just wave back. If so, we sit at a table (at times with a puzzle she can help us with) until she comes to us or an RA selects the opportune moment to direct her to us. Please see the prior post on her three “no”s.

The greeting. This we learned from the Home Instead caregivers two years ago. Arms wide open, “M__ how are you. I am H__. I am so glad to see you again.” Then a big hug, and sometimes a kiss. This continues at Provision Living.

You and the items you bring are now her memory. Or you can review the yearbooks or the family reunion books with her that we have here.

We all have to eat. We can use the main dinning hall, or a memory care activity room table across from their dinning area (the unit is full). Breakfast is from 7:00 to 10:00 cooked to your choice or 8:00 to 9:00 in memory care.

The noon (11:30 to 1:00) and evening (4:30 to 7:00) meals are from menus. There is about a 15-minute wait for special items like a hamburger or BLT.

With the exception of a meal, be prepared for a visit from 15 minutes to an hour. On good days my wife can have a good time with one or two persons. Be prepared for the pauses she needs to respond.

I can tolerate visits by knowing she can live happily in her world. She does not have to “live up to former standards”. She can be who she is now and still enjoy sharing who she was then. Dementia is a disease, not an embarrassment.

You will be far ahead of the families who approach memory care with dread only to find their family member thriving in the following months.

No NO NO

After nine months in residential care, my wife’s behavior has stabilized again. She has also been using the rivastigmine transdermal patch for a few weeks. 

The behavior of over dressing that first occurred over two years ago has returned: double socks, double pants, and triple blouses. This now occurs after several weeks of dressing with little assistance.

Over two years ago I learned that “no” was conditional on the state of her “agitation” or the worries, as we then called this state. Just wait 3 – 5 minutes and repeat. Usually after 3-5 attempts the “no” became “yes”.

Now there are three forms of no. The first is a soft “no” with no change in behavior. She continues on with what she has in hand. The second is a clear “NO” emphasized with her traditional right hook that never touches anyone or anything. It often includes that raised eyebrow that silently controlled our kids.

The third “NO” includes a teeth-clinching grimace and a blow to the person involved. The stimulus is touching or attempting to remove something she is working with or is near but has not finished working with.

New employees over the past few weeks now ask “Miss M__, do you want to . . .” or “M__, can I take . . . “ and stand clear for the answer. Hitting has stopped.

For months I thought that short commands needed to be delivered in a rather clear and demanding voice. Asking a question for her to respond to seemed a waste of time. Now even the most soft-spoken residential assistant (RA) can get M__ into the shower or bed in a few minutes.

Last night I finally had an RA confirm the art of distracting and redirecting. There needs to be a break in attention. At that moment she can respond to instructions. The pause may only be a fraction of a second; putting something in its place and then (in an instant) stopping or turning to look for something new, for example.

6:54 pm. My wife said, “Lets just get ready for bed”, as we came back from the evening meal. She was smiling and happy. In a few minutes she was in her nightgown. This has never happened before. She is now lying down chewing two of the last pieces of Double Mint gum from our granddaughter’s wedding last week.

She wants to vote. I can still order absentee ballots by email.