Tuesday, July 11, 2017

Certificate of Need

The setup is simple. A facility has a hundred rooms or units. Ten have two bedrooms. That can count as 110 beds.

Rent a two-bed unit to one person and you have one extra bed. Rent a one-bed unit to a couple and you loose a one-bed unit to rent.

No one, it seems, foresaw the increase in the need for couples. Three companies were at the Missouri Health Facilities Review Committee (MHFRC) hearing yesterday to request additional rooms to adjust to the changing market with no additional cost or change in rooms or units.

Provision Living at Columbia was tenth in line. The company before us asked for 30 additional beds. The presentation seemed to be a perfect introduction for Provision Living’s request. Couples moving into memory care was far more common than I was aware of. My wife and I were not very unique in doing this. Then, something when wrong.

Asking for so many beds made it suspect of “dirty tricks” that I will discuss later. The issue was decided by granting half the requested number of beds.

Kim made a clear short presentation, building on what had already be presented.

A short discussion followed Kim’s presentation among the committee about having set a precedent of granting half of such requests for correcting bed counts for couples. We were in trouble.

The committee was about to vote when the attorney reported they had one more person: me. Most presenters, like me, had been cut off at a three-minute time limit.

I replaced my one-page discussion with the suggested talking points by the attorney plus my wife’s request:

1.    Married 59 years, in another month.
2.    Cared for wife at home, with health care for one year.
3.    “Don’t put me in an institution.” We stay together.
4.    Residential Care for Two blog on our struggles to find care.
5.    A reasonable second person fee makes this possible.
“You are out of time.”

Immediately the person who makes the motion for the committee to second and vote on, did so. "Second." Vote: All yeas. The five-hour wait was over. The attorney knew what we needed to do.

The Certificate of Need was created in 1974 when hospitals were building far more rooms than needed. To remain profitable, they had to divide the cost of the empty beds among those that were used.

So; simple; control the number of hospital beds and lower the cost to patients. The federal law was repealed in 1987. Several states then dropped their CON law too. In general, normal business competition will determine what companies will thrive or go bankrupt. The rest retained the Certificate of Need.

The Certificate of Need, in Missouri, adds another layer of competition and politics. The committee is composed of state representatives and senators and a few other people who seemed to be well versed in the law. They seemed to work very well with one another. Their humor livened up a long meeting.

In general, each company was able to find lawyers and expert consultants to verify the validity of their requests. One attorney even took a position for one company and against the same position for another company!

One case took about two-hours with many people presenting. They had everything in order to start building except for the Certificate of Need. Their manipulation of the facts and non-facts was highly creative.

This left them open to the only presentations we heard that were against granting a Certificate of Need. Their ten million dollar investment was deigned a certificate.  

Those speaking against the request, provided a fascinating insight into the residential care industry in St. Louis. The labor market is in trouble. There are not enough people to staff new assisted-living facilities. (Assisted Living here includes Memory Care.)

This results in new facilities hiring away from existing facilities. Wages rise. Worker satisfaction increases. Overtime increases. And turnover goes from 100% to as high as 125% a year. They like the work and the money but not the hours.

This has an effect on residents in assisted living but is crucial for residents in memory care. You need to ask a facility, “What amount of overtime is needed in memory care?” and “What is the turnover rate in memory care?”

I ran into the entire set of our caretakers this morning on my way to breakfast. They were visiting at the change of shifts. I was concerned if my wife’s weight was a problem when she got up from a bed. How much had she gained? Two ounces in the last month. They each commented on their observations. They were way ahead of me. This could not be possible with a high turnover rate.

If the facility with 100 rooms with 10 with two beds (110 total beds) has 80% rented (88 beds) is granted 20 more beds (130 total beds) it then changes rank from 80% occupancy to 68% occupancy.

Dirty tricks is to request a large number of beds to prevent other companies from building in competition, or adjusting beds, to meet the need for couples. The committee seemed to make projections on need based on the fixed average of past years rather than on the every increasing rate of need for couples.

One must wait two years before another request can be made. This forces one to request the most beds the committee will possibly accept. Dirty tricks thus contains two games.

One of the committee members brought up a third game that may be being played but which they question the legality: Rent a bed in a room that falls under their jurisdiction and then rent the same room (and possibly the same bed) to a spouse as a second person, independent care; that does not fall under their jurisdiction.

We learned at the Residents Council meeting this afternoon that the additional beds Provision Living at Columbia were granted will allow several waiting couples to move in over the next few months. An equilibrium in bed use between couples and singles may not exceed the new bed assignment limit during the next two years or it may.

Saturday, June 17, 2017

Mythos and Logos

I just finished reading “The Battle for God, A History of Fundamentalism” by Karen Armstrong. The book was mentioned in the Columbia Tribune last week. Karen Armstrong was the recipient of a high award in Spain for her books on religion.

Living and working in an academic environment, I have experienced part of the events she reviews. It is like having lived the past 70 years looking out at the world through a square inch hole. The book presents the entire view in a perspective that I was not at all aware of. I knew of events, but had no idea of how they may fit together.

My response to students from the monastery near Maryville, who did well in the General Biology course until the word evolution came came in to view, was to say, “Don’t limit your God. Because we now know something about how creation works, that does not take anything away from God. Actually it makes creation more marvelous as we can now appreciate how it works. AND is still working. The creation is not finished.”

I got a surprise this morning from the little robot that lives with us. I carry it in my pocket. It evolved just a decade ago.

Last night I clicked the alarm for 6:00 am. This was about the fourth day. I wanted to get to breakfast when it opened. Since about six of us eat about the same thing each morning, the server greets us with “special” or “the usual”. We do not have to wait to be waited on as is the case later on with the dining hall filling up.

Click. A menu popped up requesting me to respond to a bedtime application. My iPhone was smart enough to know what I was doing. I filled in the need information and went to sleep.

This morning I was partially awakened by someone’s music. It varied from soft to louder, with each cycle getting a bit louder. This went on for six minutes before it occurred to me what was happening: this was my wakeup call. The genie in the sleep number bed reported that I actually woke up at 6:00 and then waited six minutes (restless time) to get out of bed.

We need myth and logic: religion and reason; God and science. Our relatives in San Antonio introduced us to the Saturday afternoon non-denominational community mega-church. Provision Living at Columbia streams the Crossroads community church here in Columbia into the theater. Members of the church, who now view the service with us in the theater, report that the theater overstuffed chairs are a great improvement over pews for the elderly.

Myth looks back in time. Logic looks forward in time. Each has it place in human existence. Some people believe in myth, some in logic, and others in both. There is nothing wrong in believing in both. In fact, what I get from the book, is believing in both is healthier than in just one.
The book makes a good case that modern man has great difficulty in thinking like the pre-modern myth thinkers. More than one event in the Middle East was pulled of with the expectation that the end result would spontaneously develop as expected with the actors only starting the event. Applying myth were logic is needed can get yourself killed (and a lot of other people too).

During the time I have been reading, I have also been attending a meditation class three times a week.

God spoke to the Jews in dreams. The Moslem tradition is based on meditation.

I have reacted the point where time is lost. It is also difficult to tell when I am asleep or just suspended inside an empty shell of my body. The number bed reports that I am asleep for say 30 minutes when I judge the time to be less than five minutes. I really need to get something to replace the BASIC body monitor that includes heartbeat, sweat, and skin temperature.

Also my inward directed experience is still pretty much a swirl of grey clouds. I have yet to get a clear color picture of the things mentioned in the guided medication.

The most puzzling thing is that before, I would go directly back to sleep if I got up in the night. Now that I am interested in defining sleep, it may take several minutes. It seems that wanting to got back to sleep quickly may produce the opposite effect. I think I am having that same problem with meditation. "Relax."

The sleep number bed can sense heartbeat, motion, and breath rate. This produces restful, restless, and out of bed. This is logical. The leap to sleep is myth.

The report states that it took me 45 minutes to fall asleep. It also shows that the first hour in bed was 49 minutes restful followed by eight minutes restless. This means being restful does not require me being asleep.

The three red out of bed bars are of uniform size but represent different times of being out of bed and restless: 1 minute out of bed/3 minutes restless; 3 minutes out of bed/3 minutes restless, and 2 minutes out of bed with 1 minute before and 6 minutes after restless. [The blue shaded one-hour slider provides these details.] That means it takes 45 minutes to define sleep the first time and 3 to 6 minutes later on. The software "learns" based on averages, to my knowledge.

The facts are interesting but they do not define the time I am asleep. It took 45 minutes for the sleep number bed to figure out that I may be asleep at the start of the night. It then calls sleep after just a few minutes after being up at night. My experience with meditation doubts this call. To say that I went to sleep AT 45 minutes is a myth. Marketing often includes easy to accept myths.

I am truly asleep when I am unconscious. When a weight falls from my hand at night, I figure I must be asleep. I will give it a try. I will also see what happens during meditation in the same way.

Thursday, June 1, 2017

Maggie's Milkweed Mystery

This is one of the most difficult posts I have written. It has taken a week. Up to now I could play the part of independent observer as my wife and I traveled this tangled path from health to passing. Even after being on this journey over three years, it was not really real.

It was scary.  The heart fibrillation in December was real scary. The line between life and death was razor thin (three to five minutes). But it was not really real as she recovered. She still continues to talk in the morning, to laugh, to tease, to be pretty much herself until the “worries” catch her. Her drift from her world, in and out of our world, in the activity area is now “normal” for both of us.

Her world is most characterized by the random collection and distribution of anything she can put in her pocket, or at times, pick up and move anywhere in memory care. She shares with a few others the need to be given notice, and time, before having something of interest removed from her or her table space. A violation can bring a quick punch. “May I take this? May I wash this? May I . . . “, yields a safe way to proceed. [A few other similar residents express themselves by a loud yell or a strong grip.]

Part of 300 Milkweed Plants
Then I became active on the monarch butterfly sanctuary (see previous post). We needed milkweeds to feed monarch caterpillars. It took three years for my wife to create the milkweed garden in our backyard from seed. It produced over 300 plants each year. We needed a faster way to do that here.

I found two packets of seed at Wal-Mart for butterfly weed. One with just seed and the other with coated seeds (experiment!). I also got a 36-cell seed starter kit.       

Milkweed Seeds
I put a few seeds of each kind on a shallow dish of water. The coated seeds sank to the bottom. The uncoated seeds floated until I touched them. The floating seeds germinated in three days on the south window ledge (17 April).

I added a piece of white paper towel to the dish with all the seeds on top. Now all had maximum access to oxygen in the air. The remaining seeds then germinated over a period of more than a week. They also endured several trips to various parts of our apartment; some times more than one trip a day.

Two Expanded Disks
The seed starter kit was watered. The little disks of compressed peat expanded into little brown haycocks. I transferred the very new seedlings and added enough uncoated seeds to fill all 36 expanded disks. 

Another Missing
A few days later two of the disks were missing. I found them in her bathroom toiletry tray (23 April).

A week later another went missing. I did not find it. There was fiber on the bathroom sink drain (2 May).

Crumbs on Daybed

Then one of the best three plants, that was first to germinate, went missing. Crumbs were on the daybed sheet (7 May).

Third Best Missing
The third best plant is missing (9 May). Why did she pick the three best plants; about an inch taller than the rest?

A caregiver was in the apartment as Maggie turned from the window behind the daybed. She had an expanded disk in hand with part of it in her mouth. I was shocked (The caregiver was amused. This was nothing new to her). Maggie could not tell the difference between a chocolate candy haycock (?) and the expanded disks?

Yet another plant is gone (19 May). I found it under the heat exchanger behind the daybed (20 May). [It is still there.]

The next day the entire tray traveled to the dining room table during the night (20 May). She has not bothered the remaining plants, since part were transplanted outdoors (29 May).

We have removed everything in the apartment that she can eat that could be harmful or it is locked in the file cabinet. Newly purchased garden tools are all in the car trunk that is parked by our apartment and milkweed patch.

She fell as I was writing on this, this morning. Her legs were badly twisted. Once again she seems unharmed. We will know in a couple of days. Time to go to lunch (dinner in the old days).

We will never know if Maggie ate one of the disks including a milkweed. We may still find one on our next through search of the apartment.

Last night, Maggie said, “I don’t know what I want to do”, when we went on a walk after supper. She really is now a creature of the moment. We need to clear out the apartment down to things she still likes and that can be seen on the shelving. The things in the sorting boxes have served their purpose and are now extra baggage.

[Back in from watering the milkweeds. The nurse said the flower decorations from the Monarch Butterfly Sanctuary on the memory care tables were removed because Maggie was eating them.]

I must now accept that all of this is real. Happiness is now dependent upon the environment skilled caregivers create in this building, fully restored (and improved) from the flood. I still have a role to play here in, “I need your help, getting these pills down and getting . . .’ when there is not another caregiver to hand Maggie off to when things do not go as expected for the present caregiver.

From time to time during the day, she still misses me. I seem to love her more each day. For now our bond grows stronger as I spend several hours a day staging getting dressed and other daily activities (including all hours of the night). [I get in lots of naps.]

Wednesday, May 31, 2017

Ruth and Esther

Sunday my wife and I attended the 11:00 am video presentation of The Crossing church in the large screen theater on the third floor on Provision Living at Columbia. This was our third consecutive attendance. She did not identify with the same type of service on our TV or the big activity area TV from The Community Bible church in San Antonio, Texas. We had attended this service several times when visiting relatives in past years.

The Crossing singing and speakers seem to capture her attention. The music is familiar. The message is simple. They have the ability to bring scripture to life in the world as it is today without having to know much about theology or history.

My wife wanted to wander after the evening meal. We toured the entire first floor. Then she headed for the front door. We sat down with several other residents near the waterfalls. A number of topics were reviewed.

“And what have you two been doing today?” We mentioned we had been to church for three Sundays in a row. “What is different?” I related the above and added that the sermon was based on one of the woman in the Bible.

“Which one?” “Ruth.” My mind went blank. I had an aunt Ruth, but that was not right.

It was one of those “most embarrassing moments”. I knew the name was the same as a relative. I could not recall it. I also could not recall anything about the sermon.

Back in our apartment, I picked up Maggie’s mother’s 1978 New International Version: the book of Esther!! Maggie’s mother’s name is Esther!!

Two strings of information became entangled. The result was embarrassment, paralysis and anger.

I wish the BASIS body monitor had not been recalled. It would have recorded skin temperature, heartbeat, and sweating. I have avoided reactions like this most of my life by being “scientific”.

Feelings and emotions lead to a world I could never trust or feel comfortable in, with one exception: marrying Maggie. I always plant more than one plant or more than one variety in our milkweed garden. The truth is in the comparison.

 [The new meditation class takes me to the world of feelings three times a week. I can relive many moments of my childhood. Floating on a spider web held up by my breath carried me back to when I could see myself from a perspective of being above, behind and to the right side of my head. I played this game many hours.]

- - - - - - -

The sermon emphasized that God is at work in our lives even though we are not aware of it. The book of Esther does not include the word God. Esther took some time to realize that the sequence of events going on around her were not just chance or a lucky set of coincidents.

 [Just now (1:46 pm) as I am writing, a caregiver returned Maggie to our apartment for a rest. I glanced out the window as I cleared the daybed for her to lie down. The repotted milkweed plants we raised from seed where in full sunlight on their first day outside. I went out and moved them to the east side of the pine tree in the shade.

Maggie wanted the door propped open. I knew where it was as I had just helped another caregiver search Maggie’s four sorting boxes for the erasable marker missing from the laundry. Found it in the last box she was working with.

Is this coincidence? Or is there a hand at work here? Our caregivers seem to show up at exactly the right time on many unique occasions.]

From the sermon, I got the impression that Esther and Mordecai were talking to one another, “. . . came to her and says . . .”. In the Bible they were trading messages because of the limited access to the palace. This does not change the message; just the style of the storytellers has evolved.

My first reading of the Book of Esther many years ago impressed me with the 75,000 people killed by the Jews. That is how things were done in Old Testament times. (And still are in that part of the world.) God’s work (evolution) is taking a long time to civilize human beings. It took two world wars (where Christians fought Christians) to produce the European Union.

Somehow I did not get it; that one of the most important Jewish celebrations, Purim (March 9-12, 2017), helps Jews to remember the fact that the entire Jewish nation may have been wiped out except for Esther’s actions. The sermon got it.

- - - - - - -

For a moment, I thought that I may be experiencing what some memory care residents do on a daily basis; a degree of being lost, loneliness, and anger in an inability to understand and to express in words what they are experiencing.

Fortunately for me, I can still read, use the Internet, and relearn (update) what is now appropriate for our times. An inability to do this, for many valid reasons across the nation, may have produced the votes needed to elect our president in training.

Now to see what God does next. I would pray that the time for wars (that created the digital age and smart robots) is about over.

What is in our brain may be stored for eternity within the lifetime of the next generation. The ability to activate this information then ends the need for quarrelsome humans on earth to continue evolution (God’s work}.

Most of the plants and animals that ever lived on earth are gone. They prepared the environment for the present plants and animals, including human beings (creations that are aware of God).

Are huge masses of human beings the final information, awareness, climax? I doubt it. An all-powerful, unlimited, God, that I believe in, must have other plans that we can only dimly discern.

Saturday, May 27, 2017

Milkweed and Monarch Therapy

Milkweed and Monarch Therapy

Slope Flowers Looking Northeast
This field of Coreopsis at Provision Living at Columbia in the spring of 2017 is the result of two years of succession; the natural process of plants competing. The first arrivals in the area create the conditions for other species to thrive. 

It is beautiful to most people. At $7 per plant in a nursery, this is what several thousand dollars looks like today and for several months to come.

The beauty was so overpowering that two caregivers made table decorations for memory care.
Table 1
Table 2

Table 3
Table 4

These decorations cost about $20 each from a florist. They last about a week.                         

What happens on this slope will also now follow two paths with very different costs. Past tradition is a bulldozer, haul in good dirt, and plant whatever is in fashion. This is high maintenance. Water, water, and water. Only a few people can now afford to live in an artificial world that defies succession year around.

The new tradition is to learn what belongs here; what has evolved to thrive here. Engineering is being replaced with husbandry. Invasive non-native plants must be carefully removed. Engineering still plays a role in killing everything above ground and starting succession over again.

[However this construction site filled a valley over 70 feet deep with an 18-foot mound on top. Any seed bearing soil was either removed or deeply buried. What is growing here now comes from a prairie seed mix applied in the fall of 2015; and a truck load of dirt added on top of the mound (the lighter area on the east side of the property). Succession then starts with this seed mix and dirt containing unknown species.] 
Pre-Provision Living at Columbia (Mapquest)
Provision Living at Columbia (2017)

The contractor did not clear, in any way, a three-acre area along the north boarder that was approved for clearing. This kept the view of neighbors from the north being a fortress on a hill and kept the view of residents in the building as a natural woods on the cliff side (with no extra charge).

A Couple of Plants
The sloping field of yellow Coreopsis points out the need for a canvas of appropriate size for each desired effect; thousands on a hillside, a dozen in a vase, and only one or two plants in a garden or a small naturalized area.         

Our next job is then to remove any undesired plants and to add plants that can compete with little maintenance. Each plant has more interactions with the environment than just its contribution to the beauty of a landscape.

The milkweed is a good example. There is one species where one plant can feed many monarch butterfly caterpillars. There are several that are ornamental and currently becoming popular in landscaping. It may take several of these to feed one caterpillar; that is, if they have not been treated with a pesticide to protect the landscape investment ($7 to $37 plus planting).

[Treated plants kill the caterpillars. The expensive beautiful poisoned plants become death traps. An attempt to help, has the opposite effect! The eggs are wasted. Poisoned host plants reduce the population of monarchs.]
Milkweeds Ready for Fall Migration Monarch Generation

My wife and I raised, indoors, enough monarchs, on our two best years, to tag 100 butterflies. Each year one was found in Mexico. We had over 300 healthy common milkweed (Asclepias syriaca) plants each year. [The author of the scientific name thought the common milkweed, a native of North America, came from Syria.] 

The Monarch Butterfly Sanctuary would return to a forest if left alone; just as it did when the fields were no longer farmed in the past. Milkweeds would be a part of that succession. In time the native trees would prevail; as they did before being cleared for the current use of the land. A stable, climax, community would return. There would be few if any milkweeds. But this will not happen.

Non-native invasive species now disrupt normal succession. Invasive species crowd out, out compete, other species; other plants and the animals that feed on them. Diversity is reduced. We need to manage succession in such a way that milkweeds can thrive in a stable environment.

My understanding is that this is not difficult for this plot of land. Just mow in the spring and again in the fall, at the proper time; before the milkweeds are up in the spring and after the plants are going dormant in the fall (drought, freeze, or deer).

Crown Vetch from Top of Coreopsis Field
The Community Conservationist for the City of Columbia provided invasive species literature on crown vetch and bush honeysuckles. The crown vetch has been pulled from the sloping field of Coreopsis (some root parts still remain). The deer are feeding down the crown vetch on the upper flat northeast area. Both of these areas will require repeated inspections and plant removal until crown vetch is no longer in the community.

The bush honeysuckles are on neighboring property. Their invasive behavior can be managed by mowing, by removing seedlings and by having neighbors replace them with native alternatives. Native Alternatives to Bush Honeysuckle by Alan Branhagen in the spring 2017 Missouri Prairie Journal, Volume 38/Number 1.

A plant survey will determine what is growing now in all areas from the 2015 seeding and new dirt. These plants then serve as indicators of what other plants to add for a stable, low maintenance environment that includes milkweeds, and nectar plants; that turns a weedy area into more than a monarch rearing milkweed patch. It becomes an attractive self-sustainable sanctuary for monarch caterpillars and butterflies, and other pollinators. Residents can have a hand in growing plants for many years.

Milkweed seedlings were provided by the city of Columbia, May 19, from Monarch Watch. Memory Care residents transplanted the 50 plugs under the direction of Danielle Fox, Community Naturalist. The resident's active participation and expectations of what is yet to come was a well-intended result of this project.

Meanwhile we can wait for the fall monarch butterfly migration to lay eggs and feed on these plants. This generation will then fly to Mexico. The plants will then be put out on the sanctuary this fall where they can go dormant and be ready to bloom in 2018; ready for the spring monarch butterfly migration heading again toward Canada.

Monday, May 22, 2017

Communication Within and Between Performance Levels

(Written two weeks ago.)

The events of yesterday again highlighted the success and failure of communication between residents and their loved ones and caretakers.

A past post reported my observation (at South Hampton Place where seven refugees from the flood at Provision Living spent three months) of my wife and another resident to seemingly communicate without words. I have now seen this happen twice here.

We were seated at a table for four; my wife to my right and another resident across from me. He said something to me. She looked at him and grinned.  Then in several small increments their smiles slowly turned into a full-face grin. My wife nodded her head and they both burst out laughing. Their faces then returned to normal.

The second time, we met a resident in the activity area. On meeting, without a word spoken, this grin and chuckle occurred. The two then went on their separate ways; seemingly feeling much better for the encounter. 

Then later in the day, a caregiver shared her observation. “M___ is such a good helper. I was just at the point of leading R____ to the dining area when M___ touched the back of his hand with hers: he stood almost straight up and the two walked the rest of the way.”

My wife has resumed walking her two patients up and down the hall, but to a less amount than before the flood. The three have something in common at the lower end of the performance pick order of residents. This is a fact, but it is still hard for me to accept.

Each has developed a unique dementia personality that swaps in and out of “normal”. Living in this memory care environment, they can be happy most of the time.

Now, in contrast, is the communication failure between memory care, assisted-living, and independent living levels, in and out of residence and the resulting mental anguish. I still eat breakfast in the main dining hall.

I mentioned to the person seated across the table from me, that I had seen his silhouette, against the glass doors, across the memory care activity area, on a prior day, as we were eating. “Yes, I was getting my wife out of prison (memory care). I just do not understand her anymore.”  He was reading all he could find and had attended ALZ meeting in his hometown.

His problem and mine have been the inability to apply generalizations and policy statements to our specific situations. We need a frame of reference that fits two very different worlds. One has a clock where time is predictable across minutes, hours, days, and years. The other has, as I have now come to realize, is not a case of no clock or a broken clock, but a matter of several clocks.

Memory care is not a prison. The only differences between memory care and non-memory care residents are that memory care residents cannot remember the door code and they get lost when they wander. Memory care is more like living in a big family, that shares dining and activity areas, than assisted living, which is more like a five star hotel where people can hid in their apartments.

He must stop relating his wife’s behavior to past behavior. He needs to attend to what will make her a happy day, today and tomorrow. She is who she is today. And that is hard to accept, if you are continuing to compare now with the past or what might have been. It can promote grieving each day rather than enjoying each day or part of day.

He must also find things to occupy his own mind and physical needs so that he can continue to share an apartment with his wife. I have this blog, the physical fitness program, and the monarch butterfly project. We still have 250 cubic feet of storage full of boxes I find difficult to sort and pitch.

“She does not seem to mind me or care about me any more.” I told him how we have visitors come to the common area in memory care. We greet my wife and then sit down at a table where she can see us. In time she will come over and visit. In time she will get up and continue her trademark activity of randomizing everything she can pick up. In time she will again rejoin us. She is in her world. We are in ours. At times they mesh.

She is fully aware of what is being said, but with a very limited past (immediate and distant) for referencing, finds any discussion meaningless with the exception of the current moment; unless there is sufficient repetition or time for her to switch between different clocks.

[Caregivers take advantage of this situation by timing diversions and distractions to fit into that two to five second space between clocks (fixations on activities). A skilled and experienced caregiver can anticipate these changes between fixations that run on different clocks. This is the main reason you want the same effective caregiver as much as possible.]

For those who can, our task is to take part in and build an environment in which we, and our spouses, can be as happy as possible. My wife and I did that in our home for a year with well-matched Home Instead caregivers three times a week. My back problem put us in residential care. We are still building the best environment here in our apartment, the common areas (indoors and outdoors) and in the fitness center (gym).

[I was up before 5:00 am this morning to write this. I have the iPhone set to ring after 20 minutes. Time to get out of this chair. Next to find a repeating timer or chime I can set for 25 minutes (20 for work and 5 for exercise) as I forget to restart the iPhone timer. This is just one more step in creating an effective health care program.]

[StretchClock allows me to set the time between short stretching exercises: 25 minutes of work and a 5-minute set of yoga exercises (stretching as we do in the fitness classes), for example. I do not have to remember to reset it. Google “repeating looping timers” for dozens to select from.]

A Most Unusual Day

(Written two months ago.)

My wife woke up under the control of the “worries”. We used to call it that before we heard of “sun downing”. But the worries happen at any time. It has a stern expression, a determined effort, and a quick slap or strong hit if challenged when it is in nearly complete control of my wife.

We needed to leave for her brother, Bob’s, funeral by 10:30. She moved at double speed in packing everything in the apartment into something. There was no interrupting her in her work. There was no time to get out of her nightgown and into her cloths. At 9:00 I discussed our situation with a caregiver. She was ordered out of the apartment with a hand signal.

The business manager (also a degreed caregiver) stopped by with equal success. Attending the funeral was problematic. “She may have been over stimulated at the family gathering yesterday evening in the (partially restored) Hearth Room”. (A group of 15 relatives lasting 3 hours from which she left in her usual way about half way, “Time to go.”)

Now several other caregivers considered a calming pill. By now even drawers from my old clothes chest were resting on the sleep number bed next to the bathroom. This has never happened before.

Packing even the Pillows
Clothes Chest Drawers

I continued without forcing her to get changed or to leave things in place. I did put many things back only to have them migrate again. And then at 9:30 she sat down to rest. No order, of removing or dressing, one would normally use had worked.

And then again, “We need to get dressed to go to church.” “Oh!”, in that soft voice of recognition and understanding. The calming pill was ordered. I held out her pants. She put them on. “Lets wait on the pill.” Socks. Shoes. She put them on. The worry spell was over. No medication needed.

There was no taking off her nightgown. No putting on her brassier. I next held out her blouse. Off came the nightgown. On went the brassier followed by the blouse. I have to get things in the right order in her world.

When we stood to sing a hymn, she saw two of the picture books her younger brother and his wife made of Bob’s life, in the pew before us. One has a high school picture and the other a collage picture on the cover. She again showed for a few seconds the same reaction as when I was finally able to tell her that Bob was gone.

I had shown her Bob’s picture on the TV that was posted on Facebook yesterday, by a family member, and then asked her if she knew who that was. “Yes, Bob”. “Now read what is beside the picture.” Obituary . . . .  A two second winch of anguish and then back to the present.

The service seemed uneventful for her. The slide show afterword did connect. Between about the third and fifth showing she watched intently and responded to many of the slides that are in the family reunion picture books that have been made for us. 

(These picture books tell a story as will as bind a collection of pictures that appear to be able to withstand a lot of use for her and for sharing with all the residents.) [They are perfect for memory care.]

She responded well to a large number of people we knew well. I have been told several times that this may just be an act. It may be, in part, but she never asked to leave the service.

The dinner after the service was a second crowd. We stood still looking for seating. A complete plate was placed on the table in front of us and my wife was directed to that chair. My wife never asked to leave.

We ate supper in memory care while other family members visited restaurants. She was content visiting with our two sons afterwards and with their departure for the airport. Everyone seemed in good spirits.

This is then another time in which my wife has gone from “highly agitated and over stimulated” to normal behavior solely in response to not forcing her to perform by the clock. At no time did she jump up, “It’s time to go”, or signed, “No. I am not doing that.”

She has spent almost three hours playing with her keepsakes this evening. At 9:00 pm she is still not ready to let a caregiver help her into bed. She is now busy putting a few things right in the apartment rather than randomizing them. (I know this happens in the night at times, but have never seen her do it before.)

A most unusual day made possible by a number of family, friends, and caregivers. A thank you to each one.

This day presented the interplay between skilled, radiant, caregivers at all levels and my wife’s behavior at any one time. A significant time period can be as little as two seconds. The same behavior can support many stories; all of which can be wrong and all of which can be true for a moment.

- - - - - - - - - - -

Bob’s wife passed one month later. She was watching TV and playing solitaire. She was Bob’s Alzheimers caregiver for over 10 years.

Sunday, May 21, 2017

Sitting Correctly

"Sit up straight." " Relax." How is that possible? What does it feel like? How can it be done without a trainer observing you?

After almost a year of nearly daily classes, I am beginning to find answers. The complete answer comes when you can do this by yourself.

For decades I thought I was sitting up straight. Then I found the sitz, sitting,  bones. Then I became aware of where my shoulders should have been. And lastly, I learned to balance my head, relaxed.

None of this could be done until I could sense, feel, something related to the right and wrong way of positioning, one muscle at a time. This sensation can be the same or different from pain. Pain sets the 
limits for that day.

Pain is tricky. Where one feels pain can be far removed from the cause. Several causes can produce the same pain.

My experience with weigh training, chair yoga, and tai chi has provided three views of the same situation. “If it hurts, stop. Stay within your pain free zone. You can go further in the next session.”

The reason for caution is simple: Irritated nerves, muscles and joints may take several days to heal before progress can again be made in training these parts.

We cannot sense body parts and movements at the lower, quieter, level needed to experience training that is appropriate for seniors, if pain is present.

[I attended my first meditation class yesterday. This now provides a full set of experiences from feeling great to physical pain and to mental anguish.]

So, how to sense sitting up straight and relaxed? The answer borrows from all three [four] training methods.

Sit in a hard chair to make it easier to sense your sitz bones. Mine immediately hurt. I therefore use my vest as a cushion in class.

Roll back on your bottom to feel your tailbone. I don’t feel mine, but this is not sitting up straight. It is how I have been sitting for decades to avoid pain from my sitz bones.

Next to stack your backbone in the correct relaxed position. Start with sitting on the sitz bones. Then to find where “up straight” is.

Lean to the right. Center. Lean to the left. Center.

Lean forward. Center. Lean backwards. Center.

Repeat as needed to get all four centers at the same place.

Lift your shoulders as high as you can and then DROP them. Repeat 2-3 times.

If all goes well, you are now sitting up straight and relaxed, except for your head.

Relax your neck. Your head will probably fall forward. Repeat the above four centering motions with your head. Find the point where your head remains balanced on your backbone. This may require positioning your neck as if your head is being pulled up by a string.

Take a deep breath, fully expanding you chest. Sense how this alignment feels for several seconds. 
Repeat 2-3 times.

Now stand up as a proud owner of a properly aligned body. Practice walking this way. I back up to a wall for realignment in the hall when I feel I am loosing my proper balance.

The body and head centering motions are both stretching exercises and show you where your proper posture is. Practice establishes this position in your muscle memory. Pain related to improper posture may be eliminated or reduced for a period of time. Your attention is being diverted from pain to learning how to feel good.

The most frustrating part of this is to be totally pain free for minutes to hours and then have it return with such intensity as to almost take me off of my feet. Such a violent return generally takes place as I am walking down the hall in memory care. I have yet to fall, but my right knee can buckle.

Or the back pain starts as I lure my wife out of our apartment. That can take up to 15 minutes for her to touch and set everything in place, or a caregiver comes by and assists me.

Allergies, stress, improper posture? Plastering and painting? At any rate, the fitness classes are allowing me, in general, to fee good by the time each one ends. Each new set of exercises seem to make something snap in a new location in my back and then feel better.

Thursday, April 27, 2017

One Month at Home Again

We sorted out the apartment yesterday; 12 hours, and more time to put away everything today. We found enough silverware to set all the tables in memory care once again; and half enough napkins.

We did not find the TV remote (suspect it has been taken to the common area) and two seed starting plugs (just found them when I got into the bathroom cabinet this morning).

My electric toothbrush was missing last night. I found it in less than three minutes in the keepsake shelf. We are about set up here as we were in South Hampton Place where important stuff was locked up and the rest could be found in less than five minutes.

Three of the large clear plastic tubs that fit under the bed will be in storage. Our two worlds can again exist in the same space.

Three days ago I woke up feeling great. This happens a couple of times a year. It gave me the energy to get my wife’s keepsakes organized enough that she can play with them again. It is no fun to play dominoes if there are one or two dominoes in very container, of all sizes, in the apartment.

I also ended working on investing the money credited to our account because of the December flood at Provision Living at Columbia. I hate to be forced into making decisions when I do not have all the available facts. I don’t mind the unavailable facts as they can be easily created as needed.

One noticeable change in the whole memory care group this past month is that they seem to be calming down; perhaps even slowing down. Our two travelers, who spent hours discussing walking, driving, hitch hiking, sharing a ride with their car, truck or motorcycle (which neither had) during our two months at South Hampton Place, rarely even mention these plans now.

Falling is still our number one enemy. One resident fell, broke her hip, hospital, rehab, and back while we were refugees. She has been moved to the apartment closest to the activity area, is under continuous watch, and restricted to a wheelchair. She is just unsteady. We now have three or four caregivers watching (working with) about 16 residents during the daytime and two all night.

The fitness classes emphasize getting up and sitting down and balance (fall prevention). For these classes to be effective, residents must practice a number of skills repeatedly until they are part of “muscle memory”. I discovered this happening to me after one or two classes a day, five days a week, for the past month.

The down side of summer coming on is the tobacco smoke (an unresolved issue in the entire residential “health” care industry in Columbia). With the patio doors open to the north and the windows open to the south, the smoke comes in strong enough that the caretakers on duty quickly close the patio doors.

Only twice in 16 months has this been strong enough to trigger one of my allergy reactions that is specific to second hand smoke; that can be a “stop in your tracks” spasm in the lower abdominal area on the following day. My nose becomes congested from being too close to smokers who return too soon after a break. Dust from the continuing repair of the building is also a problem; some four months after the flood, that should never have happened.

It is now 10:30 am. My wife has finally started putting things into “her” under-the bed plastic tub. 

The wastebasket is under my desk out of her way with me sitting here. Otherwise she will redistribute the contents or, as at the hotel, pack it full of anything that remotely fits.

For most of the time we have been in residential care, if the day turned sour it stayed that way for the rest of the day; the exception was a ride in the car. Now she can switch from one to the other in a matter of minutes for no observable reason, any time of day.

The missing sheet returned
She can also find things. Not at the moment, but 20 minutes to two days later. This delayed response also shows with her cloths. No! And a few minutes later, after the caregiver has left or I turn to working on this desk, she does the very thing that needed doing.

I printed out two sheets of paper; went to the bathroom for something; returned to find the top page missing. A 5-minute search failed. We talked about this for a while. The next time I returned to the apartment, the top page was back.

She had a blouse over her nightgown. “Lets take the blouse and nightgown off” “We will put the blouse back on.” “OK?” NO! [Time for several variations of this.] It hit me, get a third blouse. “Lets put this on.” She immediately removed the blouse and nightgown, and put on the third blouse. [3:00 pm and we have the same situation except now she still has the nightgown on.]

She is ready to fight her way out of memory care at times that do not seem related to finding me. We ended up near the door as I was going to a fitness class. I sat in a chair. We talked. Several people entered and invited my wife to go with them back to the activity areas. Then one came from the activity area and asked, “Would you like a treat?” The puzzled, belabored expression on her face vanished. She took off faster than the caregiver. We just need to find the key that unlocks the “worry’s” grip on her.

Pills are now routinely offered in the normal fashion with several variations, including me. Next in ice cream or chocolate pudding. Next the caregivers check to see who is on duty, at the top of the peck order in successful attempts.

A short term calming pill is very rarely used (less than once a week). Most often, we change her environment after two hours randomizing our apartment or after shorter times elsewhere.

I found her the other day seated with her family-tree book and the mechanical cat in the activity area. She was calmly waiting for me to return from a meeting. This had been arranged to resolve a confrontation at the door.

Time to find a Monarch butterfly feeder for our window. Seems they like Gatorade and Juicy Juice.

Thursday, April 20, 2017

Investment Damage Control

The last meeting we had with an attorney and a financial manager 14 years ago, when we set up a non-revocable special needs trust for our daughter, was devoted to playing the devil’s advocate. “Lets review everything that can possibly go wrong with what we have written down in this will.” Now to do the same with the S&P 500 ETF reviewed in the past posts.

On the positive side, we have been advised that we may not run out of money living in residential care. We may not have to qualify for Medicaid. There may be an estate more than having everyone gather at Orange Leaf for a treat of his or her choice.

A prior post establishes that even with a 10% decline in the S&P 500 ETF, it can recover in between 2-3 years on average. The 5-year CD time span can be divided into two periods (of 2 1/2 years each) for comparison with the stock market.

Lets assume that half of the investment is unexpectedly needed at half way to five years. (An expected need would suggest a 2-year CD.)

CD damage control could be to invest in two 5-year CDs; save the $10,000 pot in two fractions. The cost would be one year of interest any time after 10 days from purchase ($5,000 * 2.3% = $115).

Stock market damage control could be to sell $5,000 of shares at a cost of $6.95 per trade. This assumes no change in share price. (This ignores the option of selling less than $5,000 as needed.)

The two above short term methods of damage control do not include the dynamic nature of the stock market. The CD is totally predictable. The ETF is subject to short term and long term trends that occasionally erupt into sudden large rises and falls.

The current 5-year CD earns 2.3% interest. The expected yield on the S&P 500 ETF (dividends and normal increase in value) is about 6.0%. Buying a CD is damage control, for the ETF,  costing about 4% from day one. (The CD is needed when there is insufficient time for the stock market to recover from a decline.)

S&P 500 Dividends
The S&P 500 dividend yield provides a tricky insight into the stock market. The years of high dividends are also the years of low prices ($2/$50 per share = 4%; $2/$200 per share = 1%). The entire historical trend is to a lower dividend rate (%) because of a higher share price ($).

And then something that has always bothered me is the way price is marketed. A 50% correction ($100 * 50% = $50 but is then listed as a 100% increase ($50 * 100% = $50; $50 + $50 = $100). This extreme change only happens if you sell and buy. Investors hold. They see a decline and then a recovery of 50% (-$50 + $50 = zero change in the pot). There is no 100% increase.

I interpret the statement that 2/3 of the time share prices were above 20% or below -10% of the average, also reflects the change in basis when prices fall (from the full pot) or rise (from the residue of panic selling).

A second insight, from the above post, into the nature of the stock market is the variation in prices. Only five times, in the past 42 years (12%), has the market been within 10% of the average. This makes sense. The stock market is a free wheeling system that tends to “hunt”; to overrun before changing course (like someone learning to balance on a bicycle).

This is normal human nature. The search for profit slowly drives prices to their maximum. Fear of short term loses, drives prices to their minimum, as people leave the market. I have found a number of ways built into the process of trading that limit loss and that take a profit before the price falls again. These devices become increasingly important as time to sell is reduced from twenty years (investing) to one minute (gambling).

So, CDs or S&P 500 ETFs (2.3% certain or 6.0% on average)? How long one has been in the market has no bearing on how to exit the market. (You expect to have more money, the longer you have been in the market.)

Waiting Period for Price Recovery
There seems to be no way to pick the best time to enter the market. But there is clearly a best time to exit the market: when you sell at a profit. My estimate is that waiting period, for an optimum time, can be around three years.

So, at 2 ½ years the unexpected happens. The 5-year $5,000 CD at 2.3% compounded interest for 2 1/2 years, minus one year of interest, yields ($5,293 - $115) = $5,178 for a gain of $178.

As an ETF, the $5,000 would earn, on average, $786 (6% total expectation). The increase over the CD is about $600 or $240 per year if all went well, about 12% of the time. The price for damage control by selecting CDs rather than ETFs, on average, would be $20/month.

Assume the market fluctuates +/- 10% ($500), as it, in general, does; the resulting yield would be between $286 ($786 - $500) and $1,286 ($786 + $500). Even at 2 ½ years, the ETF could be expected to match or exceed the CD, on average.

At five years and no damage, the two, $5,000, 2.30% savings CDs yield $11,200 with limited risk; the ETF is estimated to yield $13,380 for a difference of $2,180, on average, for taking unlimited risk. (Or lose $2,180 if all goes very badly on exiting the market.)

If we anticipate the unexpected, we buy two 5-year 2.30% CDs. If we do not anticipate the unexpected, we invest in ETFs with the expectation of more than doubling the return from the CDs down to an equal yield, on average (assuming an exit period of up to three years, a limited sell order, and a good credit card).

I have laid out the playing field; now to watch one of the many games being played.