Blood Pressure Management

My fingers were so puffed up, when I woke up, that I could not make a fist. This happened for two days. I mentioned this at a care plan meeting a couple of months ago.

“You have a doctor’s appointment in a week. Take your blood pressure each day before you go.” So, I did. I also took the monthly Cedarhurst blood pressure and heartbeat measurements.

Cedarhurst Blood Pressure and Heartbeat

The Mayo Clinic reports the Pulse Pressure is a fair indicator of heart health. Any thing over 60 is bad news. Mine, measured by Cedarhurst, my meter, and the doctor’s office in October was 160 – 77 = 83!! But in July it was 60, when I was in my best health for the year 2019 with a near normal blood pressure; working about an hour a day on the Monarch Butterfly Sanctuary. 

The verdict was to add a second blood pressure medication, Lisinopril, 10 mg, and add more physical activity to my wintertime life. [Daily fitness classes have resumed.]

Measuring blood pressure is like counting sparrows under a bird feeder. I used our old Omron BP785 meter. I used a number of ways to make the measurements. Finely, I hit upon a system of measurements that could sort out the small differences during measurement and the huge differences made by stress and anxiety. 

A best fit then, was to start with a five-minute meditation after putting the cuff on my arm and verifying it was placed correctly by hitting Start/Stop and hitting it again when the OK symbol showed. After the five minutes to reduce distraction; hit Start/Stop for the first reading.

My arm rested on a small pillow on our dining room table.  That put it at the right height and made it comfortable for the time to get five readings. As soon as the unit turned off (two minutes), I hit the Start/Stop to get the next reading.

In general, the sets of five readings show a small steady decline for all measurements. The occasional outlier can be attributed to having to reset the cuff. I got better at this as time passed. An outlier can also be produced by unexpected activity in Memory Care One and to trying to use a timer; both can trigger the startle reaction.

Thirteen Day Blood Pressure and Heartbeat

This chart shows that nutrition, exercise and physical therapy, during a 13 day, less stressful environment, can produce marginally normal results without medication. But the diastolic pressure is getting too low for good perfusion of the heart muscles. Day time is about OK.

Six Samples over One Day

Six samples taken on November 8, with a high stress condition (the third monthly bill for therapy still in error by over a $1,000 and the only copy of the bad bills lost somewhere after our move out of the apartment for two weeks and back; along with other factors) show a very different story.

My blood pressure (red) was dangerously high over 180 mm Hg. My skill at taking the readings yielded almost uniform heartbeat counts (grey).

My diastolic pressure (green) fell below normal. It fell too low on November 9 after taking the first Lisinopril the previous evening. It remained there for the next three days. Lisinopril works. It relaxes blood vessels, they enlarge, and blood pressure falls; with little effect on heart rate.  

My systolic pressure did not remain low but rebounded about 20 mm Hg. Stress. Without Lisinopril it might have rebounded twice as high.

November 7 and 11 are somewhat comparable. Each has one blood pressure in or near normal. The values are lower for both on the 11^th. The systolic pressure (red) is still a bit high but the diastolic pressure (green) is now too low.

The persistent high pulse pressure (systolic – diastolic) is not good. I have been examined twice over the years for heart attack with no definitive conclusions. I do not recall, or never knew, why this was done.

I am willing now to let the meter do what it is designed to do: sum three samples, one minute apart, each day. We will never know the actual readings, and the highs, and the lows. But, in general, that single average is about all the doctor needs to know to manage blood pressure. It only takes eight minutes (including five for meditation to remove distractions) instead of 15-20 minutes and a spreadsheet chart.

It appears that from now on, this will be a balancing act:

1.     Too high systolic invites ruptured vessels.

2.     Too low diastolic invites poor perfusion of the heart.

3.     Too great a difference between the above two overworks the heart.

4.     Any combination of the three is worse. 

5.     An hour a day physical work is recommended (not including daily fitness classes).

6.     Reduced stress and anxiety are essential. 

  

Brushing Teeth

In a couple of months Margaret and I will have lived here four years. We go to the dentist every six months. This time the dentist reported that Margaret needed better brushing.

Brushing was a normal part of the morning toiletry events, in the past. She also was up with the rest of the residents. She would then sleep at the breakfast table.

She now goes to bed when tired, or before 10 pm, and gets up when she wakes up or by 10 am. 

Residents have the right of refusal of everything (according to my understanding of Missouri rules). This can be used to justify almost anything not being done in practice. It removes liability for not being done.

The dental office we used has two doors. One is too narrow to pass Margaret’s wheelchair. The other placed her beside the dental chair. Becky put on the TV, down in front of Margaret. She was happy with the “Price is Right”.

Becky sat down on the end of the dental chair with toothbrush in hand after finishing with me (no cavities and healthy gums). She talked with Margaret about brushing her teeth, now, without moving her wheelchair.

The environment for tooth brushing has now been set. We are at the dentist. There are no distractions. There is a toothbrush held where she can easily see it.

“Ready to brush.” (As a command, not as a question.) One finger touches Margaret’s lower lip. The brush lands beside it. Becky keeps on talking. Time passes. The lips open a fraction. The brush turns sideways and enters.

This two-handed approach is part of routine dental practice. One for the tool and one for the mirror. It worked.

It then hit me, “Get a video.”  I did, at about halfway through the brushing. It starts when Becky stopped and then easily started again.  

Brushing Margaret’s teeth was one of the eight items that was discussed at a care plan meeting about a week earlier. 

Federal rules include a provision that if the resident refuses, but doing so puts the resident at risk, and the resident is deemed not competent to understand, then proceed with the action. 

F677 

(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) 

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and 

NOTE: In some cases, residents with dementia may resist the manner in which care is being provided, or attempted, which can be misinterpreted as declination of care. In some cases the resident with dementia does not understand what is happening, or may be fearful of unfamiliar staff, or may be anxious or frustrated due to inability to communicate. Facility staff are responsible to attempt to identify the underlying cause of the “refusal/declination” of care. 

If it is determined that the resident’s inability to perform ADLs occurred after admission due to an unavoidable decline, such as the progression of the resident’s disease process, surveyors must still determine that interventions to assist the resident are identified and implemented immediately. 

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

This seems, to me, to be the case now: bleeding gums when brushing and sent home with toothpaste for bleeding gums.

Once again, behavior in memory care can be controlled by carefully creating the environment in which it is most likely to take place. We cannot take Margaret each day to the dentist.

We can create in memory care the needed environment and train caregivers (two handed approach) to successfully brush Margaret’s teeth. A low stress setting. No outside distractions. A commanding positive approach. A timing that lets Margaret respond as desired. Uniform, regular, execution each day (as possible) by familiar caregivers who have the knack of visiting with her (distracting) as all of this is taking place.

[The more I watch the video, I am thinking we may need to brush Margaret’s teeth when she is watching Family Feud in the activity area. To this day she refuses to have the TV on in our apartment??] 

A few days after the care plan meeting a curious thing was reported. Three assisted living residents had a knock on their doors in the morning:

“Have you brushed your teeth?”

“I need to brush your teeth.”

“I came to brush your teeth.”  “I brush them myself. I have false teeth.”

[11:30am Margaret just left using the assisted walker, after her teeth were brushed using the new toothpaste. I suggested doing this while she was on the toilet. It worked. I did not see how the two caregivers did it.]

My blood pressure: 6:55am 206/99 (woke up and started writing), 7:30am 169/94, and 9:30am 154/73 (after a five minute rest, reading the newspaper, as I finish writing this). Now to get it posted with the video. Write and post in one day; it will be a rare event. 

Writing makes me feel better. I can let things go; but I can always know I can get them back from my posts on the Internet. It may have an effect on my blood pressure too. Doing anything about a stressor seems to reduce it (talking, writing, getting it done).

Pain Diagnosis

I am writing this in real time. My memory is now failing me more than ever. I just got back from the drug store with the item I went to get yesterday evening.

The process of getting memory care to function again at Cedarhurst in Columbia is having a marked effect on Margaret. Several discussions in the past 2 days led us to an experiment last night.

I have questioned how Margaret goes to sleep for months. I even took a video for the doctor to review: "Just dreaming."

A few days ago, in response to the Executive Director's question, "How are you doing", Margaret replied, "My back hurts." And that was that, except for the surprise of her speaking.

Her back is stressed by the wheelchair, the daybed, and being left in one position for over two hours.

How do you know if she is in pain? One observation was, if she stops crossing her ankles at night so tight you cannot pull them apart.

[Two caregivers, she is not familiar with, came in to take her to lunch 12:03. How that went needs to be another post.]

So, she was given a pain pill early enough to have effect before she was put to bed. Five minutes later the usual facial moves occurred. Another 10 minutes and they stopped!

[2:01 pm after our weekly Sunday visit with my youngest brother and Margaret's youngest sister in Indiana.]

I tried to lift her top leg, "Ouch".  I tried about 5 minutes later with success. A few minutes later the ankles were crossed again.

This morning I again uncrossed her ankles. They remained uncrossed until I left for breakfast,  cleaned the caterpillar rearing boxes, and put magic tape handles on the new monarch crystalids.

"Dr. Hart, Margaret is still in bed at 11:30. She does not want to get up. I informed her of our pain management experiment.

When Margaret woke up, she had bright eyes and a soft smile. She was ready for her morning kiss.

If two pain pills made this difference over night, then she must be in pain otherwise. We will repeat this again tonight. We must then find the source of the pain rather than continue with pain pills.

Is crossing the ankles a body language sign of pain? Is it related to holding the arms very tightly to the body? When this position is relaxed by massaging the thumb, Margaret immediately continues feeding herself with her left hand as if nothing had happened.

I will continue to search with, "Why do alzheimer's patients cross their ankles (legs) at night? I have yet to find such an article. Everyone knows that crossing legs is bad. Setting on a plane over two hours is horrible but not in poorly performed memory care.

I need confirmation that pain is shown by crossing ankles at night; a practice by the patient to relieve pain in the back.

10 July 2019

It is 1:46 pm. Lunch is over and cleared away. I have finished reading the Wall Street Journal left to me by the daughter of a resident who passed last week. Several months ago he gave me his sudoku book as he could no longer work the puzzles. I brought him his paper each day. She brought us milkweed leaves last summer. I am no longer playing the role of an outsider accompanying a memory care resident.

My last doctor visit to discuss Margaret's medications for 30 minutes turned into 90 minutes with both the doctor and the nurse practitioner. They even have a follow up visit scheduled next month. I need to be more assertive rather than observe, comment, and let things happen. Save the Tums.

Margaret is now using half her Xanax pill. The therapy office has become fully staffed by added two more people: physical, occupational, and speech therapy. And best of all, they are people I can work with rather than they working for me or I working for them with little follow up.

An understanding has occurred of what services the residential contract includes (we have no contract with the new owners) and what therapy provides. Cedarhurst now has a full time Quality of Live Coordinator and a full time Director of Memory Care (position open as the person left after a couple of months).

Between the QLC and Therapy, Margaret is thriving. "Now keep in mind. We are not going to cure dementia. We are working to reach her, to unlock her, and to bring out the best she can be."

There is more to performing Memory Care than having the same people often enough that they actually learn how Margaret works; but also the need to train them to perform the same task in the same way consistently. How this is to be done with short-term new hires remains to be worked out. There is a need for a register of unique tasks for each resident in addition to the text book one-size-fits-all performance.

The therapy office has the know how but the end result must be correct practice with the resident in the resident's world. [This brings to mind the experiment in which laboratory instructions were included in the 120-seat lecture hall General Biology presentations rather than in the 24-seat laboratory itself. A total failure. Learning at this level is position dependent. What happens in one setting has little effect 100 feet away in another setting.]

Arlo, the butterfly video clip camera, has captured some task performances that may make good instructional resources. Several care givers have granted me permission to download and edit them into movies. We have discussed how to make an effective instructional movie from the video clips.

Which gets me to the point of this post. There is a dismal lack of communication within the operation with the former owners and the current owner in many aspects. Memory Care and Therapy are now working together to sort out Margaret's needs.

Yesterday the QLC sat down with me and used Margaret's iPad to select software that lets a resident type messages by selecting words to create sentences. I have tried this with no success. I bring a lot of baggage that Margaret does not want to sort through. It makes her unhappy. With a new person she only has the task at hand. This service is part of the Memory Care we have not had for over two years.

And then, as I was eating the noon meal (lunch), I overheard the same comment again, "Surely they would let you use a table knife." This time I stood up and asked, "Could I take a picture?"

[The traditional way of cutting up something in memory care is to use a fork and a spoon, use your teeth, or don't eat it. Also when this location first opened, plates were fully prepared in the kitchen. There was no need for a serving knife.]

This time the meat cut fairly easy.  There was one person setting up the plates. A resident's relative pitched in to help. She found the meat too hot with a shake of her hands.

"Surely there could be a locked cabinet where you could keep restricted useful tools."

Times have changed. The hot table provides servers the means of quickly adjusting serving size for each resident. Residents can have seconds. Now servers need a way to quickly make the servings.

Perhaps this post with actual iPhone 8 video, spontaneous and un-staged, will help resolve the issue.

Draft 3:35 pm. Only once have I written a post in one day.
Posted 6:00 pm. After the evening meal.

Memory Care Monitoring Rules

A Missouri bill has been introduced to regulate resident apartment monitoring by family and/or a designated person. https://www.house.mo.gov/Bill.aspx?bill=HB675&year=2019&code=R

Reviews of online articles are primarily posted by attorneys interested in abuse and neglect. This requires constant recording; storage; and retrieval by court order. A video clip, motion/sound triggered, camera, however, is not a total invasion of a resident’s privacy. This limits its use in litigation. 

There are many positive uses of monitoring cameras that need to be protected from poor legislation: easily sharing the status of the resident, ordering supplies, sharing that smile generated by, "Good morning Miss M____".

I propose the video clip camera be used only as a means of transforming time and place. If you cannot be present, you can still see and hear clips of events at a different time and place.

A video clip camera with two-way voice allows you to be present in real time. This allows caregivers and family to communicate with no additional person being present (you) in a work space that is often small and busy.

The Arlo video clip camera allows you up to seven days to review the video clips. They are then deleted from online storage. They remain in your memory just as if you had been at the scene. Only the time and place you viewed the scene have been changed. 

Apartment Monitor View

After six months of learning to use the Arlo 2 video clip camera, that was purchased to study the monarch butterfly caterpillars, I am of the opinion that it can only provide general information about apartment activities: times caregivers enter and leave, personal interactions (voice and motions) and the type of attention. This proved adequate for skin rash control last year.

The camera does not pick up specific details (bruises, skin rashes and treatments) unless it is within a couple of feet from the target area, with the correct lighting and viewing angle. To find where the monarch caterpillars hid at night will require a careful placement of the camera or a motion tracking camera. 

Apartment Monitor Mount

The camera in Apartment 133 was not a botheration to long term caregivers, who are familiar with my wife and me, as long as it rested on the top of my office desk beside the printer. Mounting it as a room monitor, high up on the wall, changed this.

Our rules have been: 1. I am the only one who reviews the video clips.  2. There is no downloading. 3. Arlo deletes the clips after seven days or I delete them earlier.  

The House Bill 675, 2019, should permit a few simple rules (4) to operate a video clip camera in a Memory Care apartment; that requires no additional work or attention by caregivers then the facility cameras do in public areas (which is none).

1.    Time of use.

The Missouri bill is patterned after Texas and Illinois. They allow unrestricted use of the camera by the family or designated person, without any participation by caregivers being necessary. 

Turning the camera on and off, from within the apartment, creates a break in trust with caregivers. The camera is your presence. It can be better than living in the apartment with the resident, as I have been doing.

 [A continuous camera does need a simple means to block or turn off recording for professional reasons. That person should be recorded, blocking or turning the camera off and again when unblocking or turning the camera on again, and by so doing assumes responsibility for the intervening events and for restoring camera operation.]

2. Restricted Viewing.

Only a family member or a designated person can view the video clips. This same person could be present in the room. However, viewing video clips is different than actually being there. Our culture shuns images of a number of personal and private things and actions. The viewer needs to accept the responsibility of what clip to view and what to skip (“to step outside for a minute or two”).

3. Apartment View.

The camera will be set to a general full apartment view. This captures the spirit of interaction between the resident and caregivers (what memory care is all about).


The camera is a personal, private bond between the viewer, the resident and the caregivers. All three can communicate live with two-way audio turned on and controlled by the family member (“Hello Agnes. Does M___ need more pull ups?

A facility cannot require viewing of any recorded or live apartment video clips. Both states hold a general full apartment view and a facility camera in totally separate categories: one is private and the other public. 

4. Information Usage.

No monitoring video clips are downloaded, stored, or shared in any way. There are no records for a court to request other than your viewing memory. 

Both states allow a facility to request, in an agreement with family and caregivers, to use information from the video clips for training and health purposes.

Where camera alert monitoring of “acceptable” falls (day and night) is not provided by the facility, a video clip motion detection camera can do this at a reasonable cost to the family for fall prone residents. A call to the concierge will beat the two-hour apartment check and get attention when understaffing occurs and/or when in-house communication fails.

MEMORY CARE FACILITY MARKETING 2020

You do not go home and leave Grandma behind locked doors at Blue Bird Haven. A video clip camera is available for each memory care apartment. Training on appropriate use and viewing is free. Yi-Fi camera operation is free.

Be present at any time and from any place whenever it is convenient. You become part of the caregiver team. We do the work. You can help tailor it to her needs.

     Take part and observe the events of the day that take place in your loved one's apartment. Enjoy peace of mind. All clips are deleted after seven days or you delete them sooner.

[Etiquette: Please do not interrupt caregivers when performing a task.  Task interruptions may result in the loss of your camera deposit.]

Incontinence System Design

Designing and maintaining an incontinence system is a trial and error project. Amazon marketing states, “Ideal choice for ultimate incontinence protection both day and night”.

Then two inches below “Frequently bought together” showing the “ultimate” with bed pads.

Amazon treats both Assurance and Attends alike. The bed pads are all disposable. A disposable bed pad is used only once when soiled. Washable bed pads can be used 200-300 times. Comparable performance is then about $2-3 versus $0.20 plus laundry ($0.50) for maximum capacity.

There is no fixed cost for an incontinence wear system that is to be maintained by residents. The fixed cost, some facilities charge, is a form of insurance. Rather than starting out low and ending up high, the fixed cost fee is an average based on a number of residents. Prices and products are continually changing.

Products listed below need to be tried for effectiveness. Molicare and Attends were picked by professional memory care managers a few years ago.

The tabbed brief is easier to use at night than the pull up. The MoliCare remains odorless for over 8 hours by controlling the pH. The others required changing within 4 hours to remain odorless.

The values in the following table are rounded for easy reference. The 30-day cost is based on experience. Some months the cost may be more or less. For many people their cost should be about half of these estimates. [There are 13 4-week months in the year.]

Product           Pull   Tabbed   Disposable      Washable     Cost/30 Days

                        Up     Brief       Bed Pad           Bed Pad       Low*        High**

None               (bath towel and home laundry bedding)      $0.00       $30

Assurance                 

Depend         $0.70   $0.50      $1.00-$2.00      $0.50            $70      $200

Attends

MoliCare***   $1.70      (odorless 8 hours)                             $150    $400

Wellness       $1.70      (astronaut dry 8 hours)

*   2 PU, 2 TB, and 0 bed pad

** 4 PU, 4 TB, and 3 bed pads

*** No TB and 8-hour change

Four Make a Washer Load

Many people start the process using a large bath towel. They then seek protection during the day and into the night. Disposable (two 36 x 36” overlapped ) bed pads make sense until the number needed exceeds the cost of a $20 (34 x 52”) washable bed pad and laundry ($0.50 each).

At low flow rates, a change to higher quality items will suffice for a time. With high flow rates, none of these items will work during the day without frequent (two-hour toileting) nor at night without a good bed pad.

It is at this time that the lowest cost system is to again to select the lowest cost items with a good bed pad. The bed stays dry.

Every time I get on the Internet, Google helps me find new things based on what I searched for the day before. The Wellness Absorbent Underwear (Pull-Ups) using InconTek technology based on designs used by the astronauts claims an 8-hour dry performance for the wearer. 

The MoliCare Premium Mobile Underwear claims an odorless performance for the same time and price.  But it leaks when Margaret sits up and turns. A two-hour dryness check is more traditional than an 8-hour scheduled change in memory care.

Everything has failed her high flow rate at night, and in the day if not toileted often enough or timed properly. So back to Walmart for a last check on prices (same as online) and to find what is on the shelf.

Surprise. Assurance Incontinence Underwear, XL, $0.49; Assurance Incontinence Stretch Briefs with Tabs, L/XL, $0.53; and Assurance Premium Extra-Large Disposable Washcloths, XL, $0.05. Everything was there. We will need to watch the underwear as I have never seen underwear priced below briefs.

The wetness groin rash is back in mid-April. To date Vitamin A&D ointment is working for her yeast rash and groin rash. That is about $10 per $100 of Nystatin last year that did not work until the weather cooled down (or was it just the change in the weather that mattered?)  

I have not studied the market for subscription systems. They have a place where the convenience is worth the cost. I will need to do this if the Assurance underwear prove inadequate.

One week later. The caregivers prefer the Assurance Underwear and Washcloths. The washcloths are larger than Attends. A test online order arrived in three days free. The advantage of ordering yourself is it is easy to try different products. The advantage of a subscription order is you have to do nothing after it is tuned to your needs.

Two weeks later: This is working. Any time the shelf below is empty, of either product, I place a Walmart order over $35. It arrived free in two-three days. I have yet to find a convenient reorder button. I search for a product. A re-order screen comes up for everything I have ordered in the past few months.

If the surplus product is hidden in a closet or chest, you run the risk of running out before you realize you need to re-order. Storing the excess in sight of an apartment monitor would also be convenient. 

Incontinence Wear Services

Memory care facilities handle incontinence wear in several ways. It may be included in the overall apartment fee or a monthly charge for what is used is made. Either way, the resident need not worry about ordering and about running out of “product”. This is the lowest cost way of providing incontinence wear and with the least hassle.

Starting next month, memory care residents must provide their own incontinence wear. The corporate switch was to have each resident have an individual account with the former supplier. That changes billing from wholesale to retail plus shipping.

The two-hour meeting ended with free shipping, by all individual orders being shipped in one monthly shipment. A standing order, designed to never run out of product, is controlled by a phone call to skip a shipment when a surplus builds up.

Wipes, tabbed briefs for night, and underwear pull ups for day, were priced by the case. A case was estimated to last 12, 6, and 3 weeks, respectively for my wife. A surplus would be a full case on hand (for any product) at the time of the regular shipment. [Full cases are needed to span the time (one to three months) between regular scheduled shipments. This is not a monthly order system.]

I made two Healthy Kin online orders prior to the above meeting. The first was for all three items. The second order was just for pull ups.

                                                            Healthy Kin     Concordance

Attends wipes                                     $20.95             $30.00                         

Attends stretch briefs, large/X large   $48.95             $62.73

Attends underwear pull ups, X large  $35.95             $43.55

Total product first shipment              $105.85           $136.28

Shipping on $100 order                      10%                 free

Sales tax                                             none                8%

Ordering                                              as needed       scheduled

Shipping time                                      2 day               monthly 

This works out to be about a $30 fee to have a never-run-out service versus one that requires each order to be over a $100 for the most expensive size of incontinence wear. The fee would be much less for smaller people. A better perspective on the service fee can be obtained by comparing the price of individual items and the number needed per month from other sources.

Compare Per item in over $100 Order           Healthy Kin     Concordance

Attends wipes                                                 $0.04               $0.06               

Attends stretch briefs, large/X large               $0.56               $0.71

Attends underwear pull ups, X large              $0.71*              $0.84

* $0.82 single case order

Shipping Is a major expense. It was $10.95 on a Healthy Kin $105.85 order (10%) and $9.95 on a $35.95 order (28%). Concordance offered free monthly shipping. The cost is built into their retail price as it is with local stores.

A comparative summary follows from three local stores and several online sources. It is followed by the details of this summary.

This limited number of companies and products presents some idea of the options to be chosen from. The choice must include lowest price for a suitable product and delivered in a convenient service.

                                            THE SUMMARY

                                      Lowest Price L/XL and XL

From a store:  Tabbed Brief    Walmart          Assurance      $0.53

                        Pull Up            Walmart          Depend           $0.71

Online:            Tabbed Brief   Walmart          Assurance       $0.50

                        Pull Up           Healthy Kin     Attends            $0.69

                                           Over $100 Online

                        Tabbed Brief   Healthy Kin     Attends          $0.55

                        Pull Up            Healthy Kin     Attends          $0.69

                       Never-Run-Out Service, with Scheduled Delivery

                        Tabbed Brief   Concordance   Attends           $0.71

                        Pull Up            Concordance   Attends           $0.84

                                   Subscription Service with Discount

                        Tabbed Brief   Amazon            Attends          $0.67
                        Pull Up            Amazon            Attends          $0.74

You must either pay someone to run a never-run-out service or enlist a responsible person to make periodic purchases. Provision Living had such a person who saved residents considerable money and provided the flexibility to always have product available without concerning the person paying the rent. All companies have a convenient reorder service.

                                                   THE DETAILS

I picked out three local stores near Cedarhurst at Columbia. The first two are about a mile away. Pack price is the shelf price. The comparative single item price includes 8% sales tax.

                      L/XL Tabbed Briefs for Night Time Wear

Store               Description                 Pricing

Kilgore             Depend, 16 count       Pack   $!8.99  Each $1.28 

                        Adjustable Underwear

Walmart          Assurance, 32 count   Pack  $15.74 Each $0.49

                        Stretch Brief

                     XL Underwear Pull Up for Day Time Wear

Store               Description                 Pricing

Kilgore             Depend, 17 count       Pack  $18.99 Each $1.21

                        Fit-Flex

Schnucks         Depend, 15 count       Pack $13.99  Each  $1.01

                        Fit-Flex   26 count       Pack $19.99  Each  $0.83

                        TopCare, 16 count       Pack $11.99  Each  $0.81

Walmart          Depend, 38 count       Pack $24.87  Each $0.71

Walmart store pricing is equal to the order I made online to Healthy Kin. The problem with stores is that the product you need may be out of stock in the store at the time you visit it. Also the exact same product may be in more than one package, such as Depend Fit-Flex.

Old and New Package

A curious observation is that Depend supports stores rather than competes with them. This, I think, is the reason Depend has shelf space in all three stores. Also all three stores have different counts in their basic pack. This confuses the issue of their absorbance capacity; lower count used to mean higher absorbance capacity.

All three stores have a way to deliver:

Kilgore             $5.00 each order.

Schnucks         Uses Instacart.com for $3.99 each delivery.

Walmart          Ships directly to your address for free if the order is over $35.

This brings us to online shopping with an expected free two-day delivery, except for Concordance with scheduled monthly deliveries that prevent running out of product.

         L/XL Tabbed Stretch Briefs for Night Time Wear

Company         Description                 Pricing

Concordance   Attends, 96 count       Order  $62.73  Each $0.71

                        

Healthy Kin     Attends, 96 count        Order  $48.95 Each $0.55*

                        * (includes $10.95 shipping on $105.85 order, no tax)

Walmart          Assurance, 16 count    Order $9.88    Each $0.67

                                           32 count   Order $15.74  Each $0.53

                                           64 count   Order $30.54  Each $0.52

                                           96 count   Order $44.84  Each $0.50*                 

                        * (free shipping on over $35.00 order)

Amazon           Assurance, 32 count    Order $24.49   Each $0.83

(free shipping)                    96 count    Order $53.24   Each $0.60

                                          192 count   Order $107.19 Each $0.60

                        Attends, 96 count        Order $59.26    Each $0.67

                    XL Underwear Pull Up for Day Time Wear

Company         Description                 Pricing

Concordance   Attends, 56 count       Case  $43.55 Each $0.84*

(on account)   

Healthy Kin     Attends, 56 count       Case $35.95  Each $0.69

                        * (includes $10.95 shipping on $105.85 order, no tax)

Schuncks         Depend, 15 count       Pack $13.99  Each $1.27*

(Instacart)       Fit-Flex   28 count       Pack $19.99  Each $0.91

* (includes both 8% sales tax and $3.99 delivery) 

Walmart          Depend, 15 count        Order $11.48  Each $0.83

                        Fit-Flex   26 count       Order $17.76  Each $0.74

                                       38 count       Order $24.87  Each $0.71

                                       52 count       Order $33.80  Each $0.70*

* (free shipping only if over $35.00 order)

                        Attends, 14 count       Pack $10.21  Each $0.79

Amazon           Attends, 56 count       Order $38.51 Each  $0.74       

(free shipping)

                                              THE END

                                          5 APRIL 2019