Reverse Magazine 0723

July/August 2023

PHARMACIES and Prescription Meds

Comparing Pharmacy Services and Benefits

THE CAREGIVER AND MOTHER NATURE

Nurture yourself outdoors

STRESSBUSTERS FOR CAREGIVERS

Give yourself a break

KEEPING SENIORS SAFE IN THEIR HOMES

What's new and practical in home security

OUR AGING WORKFORCE

Working past retirement age

BOOK REVIEW:

The Four Things That Matter Most

CHAIN VS LOCAL PHARMACIES

An overview of services and benefits

4. 6.

13.

MANAGING YOUR SENIOR'S MEDICATIONS

It can be overwhelming!

16.

COMPOUNDING THE ISSUE

The unique role compounding pharmacies play in the industry

20.

KNOW YOUR COVERAGE OPTIONS WITH MEDICARE

Making the right choice

21.

LONG-TERM CARE INSURANCE ISN'T FOR SISSIES

It's simply not for everyone 18.

TACKLING THE PROBLEMS IN LONG-TERM CARE

An overview of pending legislation

PUBLISHER AND MANAGING EDITOR

Anna Gelbman Edmonds

DESIGN AND PRODUCTION

Kristina Parella

ASSISTANT EDITOR

Amy Stokes

CONTRIBUTING WRITERS

Kathy Bradley

Carl Cease

Earl Gregorich

Micah Hansen

Emma Hynek

Heather Leigh

Jeanne Reynolds

Frances Shainwald

Melissa Sprouse Browne

Caroline Ward

(Volume 1, No. 3)

Reverse Magazine is a bimonthly publication published by The F-Suite, LLC. Please email Anna@ reversemagazine.us for advertising rates and information regarding mail subscriptions and purchase of sample or bulk copies.

Copyright ©2023 The F-Suite, LLC. All rights reserved. Reproduction in whole or in part without permission is prohibited. The publisher is not responsible for the opinions or comments of the authors or the subject matter of advertisers. We welcome your comments and questions by email at info@thefsuite.com or mail to The F-Suite, LLC, 317 Bradford Lane, Columbia, SC 29223. Tel. (803) 216-1902

editor's letter

Are you listening?

I never in my lifetime thought I’d be hosting a podcast, but I am — and I love it! It helps that I’m a naturally curious (and nosy) person. I’ve learned how to ask pertinent questions in a way that makes people want to open up. All of my guests so far have been engaging, fun and eager to share their knowledge with listeners. And they’re being heard outside of South Carolina. We have listeners in California, Maryland, Illinois, New England, Canada and even Australia and Israel.

The Navigating in Reverse podcast takes a conversational approach to the topics we cover. In other words, it’s not just me running my mouth. I invite guests with expertise in topics caregivers want and need to hear about. Caregivers are busy people and have little time to research and seek out the information they need. Listening is a passive activity, allowing you to absorb information while doing something else that doesn’t require your full attention — like cooking, cleaning or gardening — or while filling idle time sitting at the DMV, a doctor’s office or in the car.

I have to give a shout out to Andy Haworth, our sound engineer and audio editor who keeps the guests and me on track and makes sure we’re producing a quality product. You can subscribe to Navigating in Reverse from wherever you listen to your favorite podcasts, including Apple, Amazon, Spotify and YouTube. And if you have a suggestion for a topic or guest, just email me!

Did you know that the articles in the magazine are also posted on our website? The digital version allows you to share articles with others, whether by email or social media. The magazine also makes a great gift. As a matter of fact, our proofreader, Amy, just gifted her parents with a subscription. Mr. and Mrs. Newman, enjoy the read!

In addition to the in-depth articles in this issue on pharmacies and medication, we’re introducing a new feature (on page 18) which will provide information on resident and patient rights related to senior and long-term care. Our aim is to educate and equip caregivers to be advocates for the quality care and services their loved ones deserve.

Did you enjoy the unusually long spring we had? I spent lots of time working, reading and eating on my deck over the last few weeks, alone and with friends. Maybe outside is a good place to enjoy your copy of Reverse — you’ll find we included an article about the importance of spending time outdoors.

Wishing you a wonderful summer!

Anna Gelbman Edmonds Publisher & Managing Editor Anna@reversemagazine.com

The Caregiver and Mother Nature

Taking the time to intentionally nurture yourself outdoors

By Frances Shainwald

We have so many reasons to stay indoors: Our favorite TV shows are on 24 hours a day, our groceries can be delivered, and we can control the air temperature. For exercise, we can hop on a treadmill or exercise bike, so why risk running into the neighbors? Though they are convincing, our excuses to stay inside prevent us from reaping many health benefits the great outdoors offers us.

Catch a few rays

We spend a lot of time and money on the business of protecting our skin from the sun and treating its effects. Between sunscreen, sun shades, sun hats and sunglasses, we work hard to keep the sun away. Despite the dangers of excessive sunbathing, a safe amount of sun exposure can be an asset to our health.

The sun is our key source of vitamin D because we absorb most of this nutrient through the skin. Vitamin D is essential for bone health and preventing osteoporosis. It also supports the immune system. Deficiency is tied to fatigue, muscle weakness and depression. Small amounts of sun exposure can help to ease certain skin disorders without causing skin damage. A National Library of Medicine article gives evidence that UVB rays help with the inflammation and scaling associated with psoriasis. Some eczema sufferers also notice relief after being in the sun.

Exposure to sun offers great mental health benefits. Fewer daylight hours during the winter months has been linked to symptoms of depression and anxiety. Sunlight helps us produce serotonin, the hormone that acts as a mood stabilizer. Sunlight also plays an important role in our sleep/wake cycles. It causes us to feel more alert during the day,

and exposure to bright light in the morning helps us sleep better at night, as explained in an April 2023 article from the CDC.

Go for the green

Outdoor shady spaces also offer enjoyable health benefits. Many studies have identified a relationship between human interaction with elements of nature and lower stress levels. In a 2019 article from Sage Journals, researchers noted that adults who spend time in natural environments have improved attention and working memory. Children who have access to outdoor spaces and views demonstrate better self-control, according to the same report. A 2019 study published in Science Advances shows that even sounds and images of nature have had positive impacts on stress levels. Research (from Science Direct) has shown direct contact with the earth through a technique called grounding can reduce pain, improve sleep and lower stress levels. One of the strongest claims is that a skinto-earth connection can act as an anti-inflammatory, reducing free radicals in the body. The simplest form of grounding, also known as earthing, involves walking barefoot outdoors; but any direct contact, such as gardening without gloves, has the same positive effect.

Take a Breath

If for no other reason, head outside to enjoy cleaner air. Regardless of air quality in your area, indoor air pollution can be as much as five times higher than outdoor pollution, according to a study by the EPA. The American Lung Association says that pet dander, cleaning products, cooling/heating emissions and dust are only some of what contribute to indoor pollution. Poor air quality is associated with several respiratory and cardiac issues, so your lungs and heart will thank you for the trip outdoors.

Plan your outing

Don’t head outside unprepared. After a short time in direct sunlight, the damage can outweigh the perks. Make sure to bring sunscreen, and lather up after a few unprotected minutes. Bring a hat and long-sleeved shirt for covering exposed skin, and consider an umbrella if you won’t be in the shade. Make sure you have a water bottle and stay hydrated, especially if you are getting exercise.

A trip outside is something caregivers and seniors can enjoy together, while mutually benefiting from the sunlight, fresh air and green space. Even a few minutes each day can have a positive impact, so turn off the TV, skip the treadmill and head outside.

PICK-UP-AND-GO

Ways to Spend Time Outdoors

• Take a walk

• Have a picnic

• Plant flowers or herbs

• Attend a youth sports event

• Read or listen to a book

• Enjoy birdwatching

• Meditate

• Practice yoga or tai chi

• Play outdoor games

• Play card or board games

• Visit a farmers market

• Attend an outdoor event

The Caregiver’s Training Program

A practical guide and useful tactics for caregivers. Step-by-step instructions for what to do, who to call and how to find help when you need it.

by Melissa Sprouse Browne, founder of

Available in Print and Kindle on Amazon

STRESS BUSTERS FOR CAREGIVERS

Stress affects every facet of our lives, so tackling it intentionally is the best defense. Putting simple steps in place can make a huge difference!

PHYSICAL

• Eat healthy foods

• Make regular doctor visits

• Schedule naps

• Sing and/or dance

• Take a 20-minute walk

PROFESSIONAL

• Turn off email notifications

• Take a lunch hour

• Use your vacation/sick days

• Learn to say “No”

• Leave work at work

EMOTIONAL

• Give or get a hug

• Listen to music

• Relax outdoors

• Play with a child or pet

• Knit, garden, draw, bake, etc.

SPIRITUAL

• Meditate

• Pray

• Join a spiritual community

• Practice forgiveness

• Read a devotional

PSYCHOLOGICAL

• Journal self-reflections

• Get therapy

• Join a support group

• Learn to ask for help

• Set boundaries

Keeping Seniors Safe in Their Homes

A look at what’s new and practical in home-security devices

By Earl Gregorich

Keeping seniors safe can be challenging. Busy schedules don’t always allow caregivers to be vigilant 24/7. Threats to their physical and financial well-being are growing in number and complexity. Not to mention, in some cases, you need to protect a loved one from their own actions. So, let’s look at a few security technologies that can help keep you and your seniors safe.

Smart Locks

As seniors get older, it grows harder for them to remember things like codes, where they left their keys and who they should or should not allow inside. It can also be difficult to get to the door in a timely manner. Smart locks can solve these challenges.

Look for locks with remote activation and monitoring. They are usually controlled with a smartphone but can also work inde-

pendently. Some locks offer voice activation and backup access using a key or key card. More advanced models might offer fingerprint or facial recognition, which is good if remembering entry codes is difficult.

Alarms can be set on locks to remind seniors or caregivers to lock the door. Audible alerts can also provide notice if a loved one opens a door and is moving about. Locks with video cameras and entry logs can also be useful to track who is coming and going.

Security Systems

Home monitoring and security systems have evolved significantly in the past several years. Complex wired systems with communication backups and 24/7 recording are still available. But these days you can also find simple wireless, battery-powered, phone-controlled systems with on-demand monitoring for reasonable fees.

Minimal systems should include a video doorbell, outdoor motion-detection video cameras, and door and window sensors, and they should offer some form of cloud-based recording. These features will be enough to allow the senior or caregiver to interact with visitors from inside or, should the situation warrant, simply monitor the environment until authorities can arrive. Battery-powered systems are surprisingly reliable but do require periodic maintenance, and the batteries can be expensive. Monitoring services have limitations on storage and require periodic interactions with tech support.

More elaborate systems may include medical alerts, open-door alerts, and integration with smart TVs and smart speakers. You may also find systems with a two-way control panel allowing direct access to security representatives. Sensors for temperature, water leaks, and glass breakage are also available with some systems.

Regardless of the security system you choose, consider the communication technology needed to enable it. Seniors in areas with weak cell signals may need a landline-based system. If wireless networks are available, check the consistency of upload and download speeds. This can impact the notification timeliness and video capabilities. Always test your system regularly.

Medical Alerts

Medical alert systems have been around for years. However, they have become smarter and are being integrated into comprehensive security systems. So much more is available now than the simple ability to call for help.

Many med-alert systems offer GPS tracking, remote monitoring and fall detection. Some of the upgrades might include voice command capabilities that work with a home’s smart speakers. Nearly all have 24/7 monitoring and offer comfortable and convenient devices in multiple shapes, sizes and application types, from necklaces to key fobs to panic buttons at the bedside. Make sure wearable devices are water-resistant.

When choosing a med-alert device, consider the mobility of your loved one. Some med-alert systems only work within a few hundred yards of the base unit. Effectiveness can be reduced by the number

of walls between the receiver and the wearable device. Wider coverage areas for when your loved one is traveling around town should use cellphone-based systems.

Some med-alert systems can be expensive. Consider the leasing and buyout options carefully. Insurance normally does not pay for these systems, so make sure to ask for discounts.

Smart Lighting

Lights provide visual safety and a psychological sense of security. Like much of the technology already discussed, lighting can now be controlled with a phone app, smart speaker or motion detection. Timed lighting patterns can help direct the daily routines of your loved one, and proper lighting has been proven to improve sleep and morale.

Setting up some systems is as simple as changing a lightbulb. Others, like outdoor lighting, may require more complex installation. Nearly all use budget-friendly LED lights. When setting up a new system, be sure to consider convenience, security and morale. For example, a bedroom light will be much more useful and emotionally friendly if it comes on dim and slowly brightens to full power.

The right application of technology can give you peace of mind and add an extra layer of protection against the threats we face daily. Choose wisely. Hopefully, you can find the right mix of tech without breaking the bank. If all else fails, there are GPS-enabled insoles on the market. No, really! Google it!

Our Aging Workforce

Financial anxiety is one reason for this projected shift

By Micah Hansen

By 2030, one in five Americans will be aged 65 or older. The rapid growth of the country’s senior population since the early 2000s is mainly due to improved life expectancy. Additionally, the largest generation in American history, the baby boomers, began turning 65 in 2011.

Americans are more likely to work past age 65 today than they were in the 1980s and 1990s. The U.S. Bureau of Labor Statistics projects almost 10% of the labor force will be over age 65 by 2030. The rise of older age demographics is just one aspect of our changing working world.

Retirement rules changed midplay

The development of Social Security and retirement benefits let older Americans experience increased financial well-being and independence through the latter half of the 20th century.

However, changes in the functionality of these benefits began by the 2000s. The retirement age to qualify for full Social Security benefits rose. Delayed retirement credits for those waiting to claim their benefits until they were past the full retirement age increased. Pension plans no longer imposed penalties for working past the plan’s retirement age. And, one of the most important shifts, jobs were becoming less physically demanding.

Along with increased health care costs, these changes left older adults thinking about their retirement security. Their concerns came to a head with the Great Recession of 2007-09, which left many uncertain if they would have enough money to retire.

In the 1981-82 recession, older workers often chose to retire. By contrast, during the Great Recession of 2007-09, many older workers chose to stay on the job market.

Already postponing retirement, older adults remained unemployed longer than younger workers and took lower-paying jobs than they’d had before. This reduced accumulated retirement benefits and potentially impacted existing savings. Many found it necessary to work longer than they originally planned.

The professional world has changed

Today, alongside the trend toward less physically demanding jobs, the COVID-19 pandemic has made flexible working situations, such as working from home, a new possibility for many. Work from home jobs could make holding a job more feasible for those who have difficulty navigating their community independently.

However, remote jobs are constrained to particular kinds of work, and their availability largely depends on the worker’s level of education. Despite the many solutions remote working could offer older workers, it

isn’t an option for everyone.

Other problems in both remote and onsite jobs exist. Ageism, for instance, is evidenced in the typically longer period of unemployment among older workers than younger workers. Inaccessibility is a factor for those who can’t easily leave their homes.

Some older adults might become physically incapable of continuing in their chosen profession. Social Security Disability Insurance (SSDI) benefits exist under certain conditions for those who can no longer perform “arduous unskilled physical labor.” But SSDI qualification criteria are notoriously stringent. Meanwhile, the increasingly automated nature of hiring makes it difficult for an application to get noticed, especially for those looking in a totally new field.

What options do baby boomers and middle-aged Americans have to prepare for their professional future if they expect to work past retirement age?

Skill-learning resources come in many shapes

Reputable online learning companies like Coursera offer free courses on a variety of topics. Professionals and experts freely share their knowledge on platforms such as YouTube. The Public Library Association also provides free online resources.

Professional education and guidance exist within local communities, too. Public libraries typically schedule learning events on topics such as digital literacy, from basic computer use to advanced Excel tutorials. And, of course, your library will have relevant books available to check out.

The U.S. Department of Labor sponsors CareerOneStop. Among its resources are local program finders for older workers, those re-entering the workforce and Social Security recipients.

Depending on one’s profession — or the profession they’d like to be in — and financial situation, paid resources such as LinkedIn Learning, trade certifications and professional association memberships are worth researching.

Despite the concerns facing them, older adults have numerous resources available as they plan for their retirement.

“The Four Things That Matter Most: A Book About Living”

By Ira Byock, M.D.

REVIEW BY HEATHER LEIGH

As a grief recovery specialist, I help individuals repair relationships from loss. The process includes learning the healing power of words. The four most important phrases you can use to transform a relationship are please forgive me, I forgive you, thank you and I love you. "The Four Things That Matter Most" resonates with my belief in facing grief with words.

Dr. Ira Byock, an international leader in palliative care, provides practical insights on how to let go of toxic emotions and grudges. Unresolved issues reside deep within many family units; anger, blame, guilt and regret keep us from reaching out to the people we love or want to love. Byock discusses the impact a legacy of pain has when it is blindly passed down through generations.

Addressing the universal excuse “I don’t know what to say,” Byock says the best way to begin resolving anything is to show up and be present with an open mind and heart. Through the eyes of his patients, he illustrates how anyone providing care, agonizing over a relationship or wanting to improve upon a healthy relationship can learn how to transform and heal.

The ability to preserve relationships with those we love is a gift. Byock details how understanding what matters most to ourselves and others can lead to a fuller life experience. A reader’s guide can be downloaded from irabyock.org to stimulate discussion about how "The Four Things” can “reveal opportunities to forgive, love and grow — individually and together — at any time in the course of relationships and life.”

Chain vs Local Pharmacies

Is there a winner when it comes to your prescriptions?

By Emma Hynek

If you turn on the television, chances are you’ll be hit with an influx of advertisements for pharmacies, prescription services and medicines. With so many options, how do you know what to choose? How do you know what’s best for you or a family member? Which option is trustworthy, and which are simply money-making ploys?

When it comes to services and products in today’s market, consumers are driven primarily by the desire for efficiency and convenience. Pharmacies are no exception. Handling prescriptions is typically considered a mundane errand, but many pharmacies have adapted their services to ensure consistent business and to keep up with competitors. A study by McKinsey & Company points to the fact that consumer preferences frequently change, meaning pharmacies have to keep up.

With a Walgreens on every corner, a variety of local pharmacies and an ever-increasing number of online options, dealing with prescriptions can go from mundane to overwhelm-

ing, particularly for caregivers.

Caregivers rely on pharmacies more than the average person. As a caregiver, you are responsible for your prescriptions, those of the person in your care and sometimes other members of your family. The best pharmacy choice is crucial to ensure you are utilizing the most cost-effective option, you have a pharmacist you can count on and the prescriptions you and your loved ones rely on to stay healthy are always available when needed.

So, what is the best choice?

Chain Pharmacies

Think Walgreens, CVS, Rite Aid. According to communitypharmacy.com, chains account for about 40% of the prescription market. You likely can’t drive down the road without passing one, putting chain pharmacies at the top of the list in terms of convenience for many people. If convenience and proximity are your priorities, these pharmacies are a great option. Chain pharmacies also often have extended hours, which is a lifesaver when you inevitably find yourself with a last-minute prescription need. Some even mail recurring prescriptions for free.

The sheer number of these types of pharmacies can also come in handy when you’re

traveling and need a prescription filled.

Keep in mind, however, that with convenient locations and operating hours come the trade-offs of longer lines and a less personal experience with pharmacists.

Local and Independent Pharmacies

Your neighborhood pharmacy is a fantastic option if you’re looking for a consistent pharmacist who knows you and your needs. This can be particularly beneficial for caregivers who deal with multiple prescriptions or needs that constantly change. Personable service is perhaps the biggest advantage independent pharmacies have over their chain counterparts.

“[T]he size and scale of most indepen-

dent pharmacies allow for close, candid interactions between pharmacists and patients, which are key to operating within a value-based care model,” explained Health Mart President Steve Courtman in a Pharmacy Times article.

In the same article, independent pharmacy owner Jason Kasiar of Illinois said personable service is what keeps independent pharmacies competitive.

“We make sure [customers] are compliant on their medications [and] we make sure that if they have problems, we’re there for them,” he explained. “I’ve driven to people’s houses to help them with their medications. I’ve opened up in the middle of the

night to take care of them, and you’re not really going to get that service at a larger retail pharmacy.”

Additionally, you may be able to find lower prices at your local pharmacy. This will vary by location, but it is always worth checking out. The drawbacks to an independent pharmacy include its business hours (less convenient when you work an 8 to 5) and the often longer travel time to get to one. However, many offer free or low-cost prescription delivery service.

Supermarket and Grocery Pharmacies

This category falls somewhere in the middle of chain and local pharmacies. According to the McKinsey study, supermarket and grocery pharmacies make up about 30% of stores and 15% of prescription revenue. A 2010 Pharmacy Times article details the benefits of these kinds of pharmacies, which include the resources and bandwidth of a chain pharmacy plus the personable service of a local pharmacy.

Grocery chains are able to provide pharmacists with up-to-date technology that en-

MUSC HEALTH HOSPICE CARE

ables them to broaden the services offered. Furthermore, shoppers are able to get their prescriptions filled in the same place they buy their food and other everyday items — a much appreciated convenience. Finally, a supermarket pharmacist likely sees regular shoppers often, allowing them to get to know customers and their needs.

Online Pharmacies

There are a wide variety of online pharmacy options available, and the number continues to grow as a result of the COVID-19 pandemic. While obtaining medicine online can seem a bit strange, it’s a great option for a lot of people. Because they erase the need to travel to get to a physical location, online pharmacies greatly expand the accessibility of modern medicine — including things other than prescriptions, like virtual appointments with a pharmacist. Another advantage is that with so many options available, you can find one that suits your budget and won’t break the bank.

According to a Global Survey Report by the International Pharmaceutical Federation, digital pharmacies benefit the pharma-

cist as well as the customer. With the entire prescription process being online — including digital health records and prescription monitoring — pharmacists are held to an increased level of accountability and can easily ensure quality, efficacy and the safe use of medications. When the process is made easier for the pharmacist, the customer benefits.

Of course, as with anything on the internet, fraud is a possibility. The U.S. Food and Drug Administration urges consumers to exercise caution when choosing and utilizing an online pharmacy. Their article “How to Buy Medicines Safely From an Online Pharmacy” provides resources that help consumers avoid falling victim to fraudulent sites selling unapproved, counterfeit and hazardous medications.

The bottom line is that no pharmacy — chain, independent, retail or online — will encompass all of the pros and none of the cons. What works best for you will depend on your individual situation. However, you can start by educating yourself on each option to help make an informed choice you feel confident in.

MUSC Health Hospice has been serving patients with life-limiting illnesses in our Midlands communities since 1978. We are committed to providing compassionate quality care to our patients and their families through dedicated professionals who are always there.

To find out if you or a loved one qualifies for MUSC Health Hospice services, or have questions, contact us as 803-425-1182.

Managing Your Senior’s Medications

By Melissa Sprouse Browne

Medication, both a trusted source of treatment and purposeful item in our lives, can make things better or bring trouble. When a doctor prescribes a med for an ailment, we’re inclined to trust the end result will be relief, a cure, an improvement in some way.

As we age, more medications become commonly used. When combining more than one at a time, keeping up with what to take and when can be challenging. Your aging loved one may struggle with managing their medications beyond getting the right pill at the right day and time.

Several common issues with seniors and meds include:

• Compliance with instructions

• Combining medications with negative results

• Affordability

• Improper use of over-the-counter medications and supplements

Dispensing and Dosing

One common compliance issue is pill size. If your loved one has trouble swallowing tablets, ask their doctor, nurse or pharmacist for ideas. There may be a liquid version available. A pill splitter or crusher will allow you to cut or crush a pill or tablet. But don’t break, crush or chew tablets without first asking a health professional; that can do more harm than good.

Dr. Daniel Young is a critical care anesthesiologist transferring to Columbia, South Carolina, this fall to become part of the Medical University of South Carolina’s regional team. Young has experience with patients of all ages serving in the emergency department and intensive care unit of a large hospital in Illinois.

“It is very common for patients to have misunderstandings regarding medications, especially when they are on multiple medicines that have different dosing frequency,” Young said.

Seniors may have several doctors, often for different specialties. Unless each physician’s office is notified of all the medications the person is taking, it’s possible to have a new drug prescribed that could negatively interact with another one on their list.

“One good piece of advice is to ask questions of the physician or pharmacist if they are not sure about something regarding their medications. In today's healthcare environment, patients often see multiple doctors, and it is very important to keep their primary care providers informed about new medical problems, medications, hospital admissions or ER visits,” Young advised.

There’s great value in having a trusted connection at the pharmacy who can check for drug interactions and alert the senior or caregiver to a potential problem. Some will prepare all of your daily medications in segmented packaging (labeled morning, afternoon and evening). Multidose packaging is available at a number of chain pharmacies, including CVS and Walgreens, as well as online (e.g., PillPack). These services can sort medications by date and time to be taken and deliver them

Dosing, understanding, affording it — even opening its packaging — can be overwhelming!

directly to your home. As a convenience, other pharmacy staples may be added to the order and delivered as well.

Another online pharmacy option is Medical Packaging Inc., LLC (medpak.com). They provide the presorted medication packets in a plastic strip, allowing the user to just tear off the one that’s next in line from a tabletop dispenser. This service provides clear identification of the patient name and what medication is needed to be taken at a certain time. No more worries about spilling or mixing up pills and being unsure what a pill may be. Mail order pharmacies that are part of the major insurers can also likely provide the presorted delivery if asked.

An important caveat exists for seniors living in an assisted living community, since medication management is generally handled by staff as a part of the residency agreement.

Reactions and Interactions

As we age, changes in our body may affect the way medicines are absorbed and used by cells. A change in body weight, can alter the amount of medication needed. A slower digestive sys-

tem takes longer to process a medication, and entry into the bloodstream can become a longer process. The drug and its byproducts may be broken down more slowly in the liver and kidneys of an older person.

This results in an increased risk of drug interactions for seniors. Drug-to-drug interactions happen when two or more medications react with one other, causing negative or unwanted side effects. Surprisingly, some food and drink can cause problems with certain drugs. For example, grapefruit juice is not a friendly companion to a statin (cholesterol lowering) drug. And as a standard precaution, don’t drink alcohol while taking medication. The last type of interaction is drug-to-condition interaction, which is when a health condition impacts how a drug is absorbed and used by the body.

Beyond the safety net of your pharmacist safeguarding your loved one from adverse drug reactions and interactions, watch out for consumables — including dietary supplements, vitamins and sleep aids — and any other overthe-counter drugs, such as eye drops and topical creams and ointments.

“There are so many supplements on the market these days. I would advise patients to have a conversation with their doctor before starting any over-the-counter medications or supplements, as these can often times have a risk of medication interaction with prescription medicines,” cautioned Young.

Staying Educated

Sometimes, physicians seek solutions for problems in unexpected places. The practice of prescribing off-label means giving a drug for something it wasn’t intended to treat; at times, it’s a solution to a problem with no other solution. There is nothing illegal or even uncommon about this practice. Off-label can be a good bet when a physician’s had success in treating similar cases with the method or when all other options have been exhausted.

“The rapidly expanding senior population is posing new challenges to the health care system,” added Young.

“As patients age, they of-

ten have more numerous and complex health issues. This system can be very complex to navigate, and a geriatric care manager can be an excellent resource to help coordinate all of the different aspects of care.”

Insurance companies and Medicare closely watch prescriptions. While Medicare has loosened regulations on payments for off-label usage, insurers don’t always pay for a drug that’s unproven for the prescribed purpose.

As a caregiver, you can learn a lot about a drug by reading the insert that comes with its packaging or by consulting an online drug database, focusing on contraindications (cases in which the drug should not be used). If your loved one has dementia or Parkinson’s disease, beware of the many drugs contraindicated for their condition. When a doctor prescribes a new drug, ask whether it’s being prescribed off-label, what evidence warrants the prescription and about the likelihood that it will benefit your loved one.

“Some of the most commonly overprescribed medications that we see in the senior population are benzodiazepines, antihistamines and other sleep aids. These medications can increase fall risk and interfere with cognitive function,” said Young. If one of these drugs is added to your senior’s list, discuss with the medical provider whether the benefits outweigh the possible negative impacts.

Financial Factors

A simple yet critical component of prescription medication for seniors is the cost. Living on a fixed income means medication costs can be out of reach unless something else is given up, like food or utilities. While Medicare Part D (the Medicare

prescription drug plan) pays for drugs in their approved formularies, there are certain windows of graduated payment eligibility where the out-of-pocket costs are higher. And some drugs aren’t covered at all.

At the end of 2021, the research firm West Health-Gallup led an extensive study on the state of health care in America, one of the largest surveys conducted during the COVID-19 pandemic on public perceptions of the U.S. health care system. The resulting report provides insight on trends in health care.

The West Health-Gallup data found more than one in 10 American seniors have skipped a pill to save money. Further, 94% of surveyed seniors believe prescription drug costs are too high, and 34% of surveyed households were worried they wouldn’t be able to pay for needed medicines in the coming year.

Good news on this front is the proliferation of assistance programs to help with prescription costs. A good first consideration is a program from Social Security called Extra Help, which helps with Medicare prescription drug costs.

Approximately half of states have a state pharmaceutical assistance program. Also, some drug manufacturers have patient assistance programs to help those struggling to pay for brand-name drugs.

Easier routes to discounted drugs can be found through a prescription discount card and comparison sites such as GoodRx. Prescription discount card companies help people save money on their medications by negotiating with pharmacies for bulk purchases and passing the ensuing savings directly to end users. The discount program then receives a payment from the pharmacy whenever someone uses their card to obtain a prescription. Many different programs offer discount cards that are free to use and are especially helpful if the senior doesn’t have an insurance plan.

The GoodRx website offers a discount prescription card in addition to the comparison-shopping feature for local pharmacies. Search by drug or medical condition to find the best pricing.

As a caregiver, you must coordinate a multitude of elements of care. For success in providing quality care and properly managing medical conditions, it’s vital to arm yourself with as much knowledge on medication management as you can garner.

AVOIDING DRUG INTERACTIONS

A bit of good news regarding drug interactions is they are predictable and avoidable with care and caution. Some of the most common drug interactions include the following:

�� Beta-blockers and asthma: Beta blockers used to treat things like high blood pressure can cause muscles used in breathing to tighten, increasing the risk of an asthma attack.

�� Diphenhydramine and glaucoma: The active ingredient in Benadryl should be avoided if you have glaucoma. Antihistamines may raise the interior pressure of the eye and make it worse.

�� Pseudoephedrine and high blood pressure: Nasal decongestants containing pseudoephedrine, the active ingredient in Sudafed, tighten blood vessels, which may cause overall blood pressure to increase.

�� Furosemide and severe kidney disease: A common diuretic, known by the brand name Lasix, helps the kidneys remove extra fluid. Those with kidney disease may not process the drug as effectively.

�� Acetaminophen and liver disease: Acetaminophen, the active ingredient in Tylenol, could be harmful for those with liver disease. Acetaminophen is broken down in the liver, and if that organ isn’t working properly, toxic levels may build and cause further damage.

�� Ondansetron and dofetilide: Ondansetron, the active ingredient in Zofran, is used to prevent nausea and vomiting. The heart rhythm medication dofetilide has a negative interaction. Both medications can lengthen the amount of time between heartbeats. When used together, this time can be longer than usual, resulting in dizziness, fainting and even death in severe cases.

�� Digoxin and amiodarone: Digoxin is a heart medication. A slight change in its dose could cause serious problems, making digoxin susceptible to interactions.

�� Bactrim and warfarin: Some antibiotics, such as Bactrim (sulfamethoxazol-trimethoprim), can raise the risk of bleeding. Blood thinners like warfarin (Coumadin, Jantoven) are amplified when combined with Bactrim and other similar antibiotics.

�� Levothyroxine and omeprazole: The thyroid medication levothyroxine (Synthroid) is likely to interact if its dose is changed. Omeprazole (Prilosec) lowers acid production in your stomach in the treatment of heartburn symptoms. When combined, Synthroid is less effective than expected.

Credit: U.S. Food and Drug Administration

What is a compounding pharmacy?

Compounding pharmacies make customized medications to meet specific needs for people — or even their pets — who need medications that aren’t mass-produced and available at a standard pharmacy. Of the approximately 56,000 community pharmacies in the U.S, only 13% (about 7,500) specialize as compounding pharmacies, according to the American Pharmacists Association. Compounding pharmacies are regulated by their state board of pharmacy and monitored for quality purposes. Compounded medications aren’t approved by the Federal Drug Administration, but the FDA regulates the active pharmaceutical ingredients from which they’re made.

Compounding the Issue

How compounding pharmacies can meet special patient needs

By Jeanne Reynolds

Apothecary and chemist might sound like terms from an old Charles Dickens or Agatha Christie novel. But small local shops like these were once the only places patients could buy drugs and medications. That changed with the advent of the global pharmaceutical industry in the late 1800s and early 1900s. Now, the vast majority of drugs are made by large international companies: Think Bristol Myers Squibb, Novartis, Johnson & Johnson, Pfizer and Roche.

Most — but not all. Some medications are still made by small local shops called compounding pharmacies.

“Pharmacists still make things,” says Janet Thames, PharmD, a compounding pharmacist in South Carolina. “That’s pretty cool.”

Compounding pharmacies can make two types of medications: sterile and nonsterile. Sterile compounds (including injections, eye drops and infusions) have a high risk of problems if contaminants get into them, so they’re made in a special environment with additional requirements. Nonsterile compounds come with a low risk of infection and include creams, capsules and suppositories.

Who needs a compounding pharmacy?

“Shop local” is a buzzword these days, but that doesn’t mean you can walk into a compounding pharmacy and ask for your medication to be made onsite.

“Compound medications are reserved for dosages and forms not already made by pharmaceutical companies as an FDA-approved manufactured drug,” Thames explains. “They’re made for very specific patients, such as hospice patients who need a certain dosage or who can’t swallow and need a transdermal medication.”

Compounding pharmacies can turn a medication into a gummy, hard candy, chewable tablet or liquid form, or they can add flavoring to a poor-tasting medicine to make it easier to take. Allergies and food intolerances also can create a need for compounded drugs. Many standard medications come in capsules made with peanut oil, but a compounded version can be made peanut-free for those with peanut allergies. Diabetics may

need sugar-free versions of their medications.

“One of the biggest things is making sure of what’s not in a drug — no dyes, no coloring, no sucrose or fructose,” Thames says. “We can control the binders, shape and size; eliminate inactive ingredients; and create higher-quality products.”

What — and who — should you ask about using a compounding pharmacy?

If you think you or a loved one might benefit from using a compounding pharmacy, “start with your physician or pharmacist,” Thames advises. “Let them know if there are things you can’t tolerate. Most people don’t know enough about compound medications until they need something and interact with a doctor who specifies it.”

However, cost may be a concern for some patients. Compounded medications are typically an out-of-pocket expense not covered by insurance, according to Thames. Some insurance companies cover these drugs under certain conditions or circumstances but may require the pharmacy to be in its network. Patients may want to contact their insurance company after receiving a compound prescription before submitting it to the pharmacy.

In addition, a very busy compounding pharmacy may ask you to prepay before making your medication, Thames says. “We have to remind patients their medication is made just for them. Once you order the drug, it’s yours.” Because the medication is customized for each patient, it can’t be reshelved or sold to another customer if you don’t pick it up.

Patients also should be aware it’ll likely take a little longer to receive a custom-made medication than a standard drug. Thames says the turnaround time to create a compound medication is two to three days for her practice.

To find a compounding pharmacy near you, ask your health care provider if there’s one he or she recommends, or visit the Alliance for Pharmacy Compounding’s website at a4pc.org/find-a-compounder. Enter your city and state for a directory of nearby compounding pharmacies.

Tackling the Problems in LongTerm Care

A look at opportunities for legislative change at the national level

By Kathy Bradley

Right now, advocates are uniquely poised to push hard for improvement in the quality of services in long-term care. More federal legislation on this front is being proposed than we have ever seen before.

The pandemic laid bare longstanding problems in long-term care. But make no mistake: It did not CAUSE those problems. Providers have been failing consumers for decades, all the while claiming they don’t need regulations and can police themselves.

According to a December 2021 article from The New York Times, nearly 740,000 seniors — one of every 100 in the country — had died from COVID-19 to that date. About 75% of all COVID-19 deaths were people 65 and older, according to the CDC data posted May 25, 2023. As of May 14, 2023, more than 166,000 nursing home residents had died of COVID-19, according to the Centers for Medicare & Medicaid Services (CMS); 3,100 nursing home staff had also died. In February 2022, the Kaiser Family Foundation reported more than 200,000 deaths in long-term care settings among staff and residents of all ages combined. Neglect during isolation also caused an alarming number of health declines and deaths, as reported by The National Consumer Voice of Quality Long-Term Care in January 2021. Many of those deaths were likely preventable had providers, consistently and over time, prioritized staffing levels, training, supervision and infection prevention and control proto-

cols (including maintaining adequate PPE). Many did not.

The devastation wreaked by the pandemic raised a call to action by our nation’s leadership. The National Academies of Sciences, Engineering and Medicine (NASEM) hosted a public webinar in January 2021 to gather information and perspectives on what happened and why. NASEM published an April 2022 report with comprehensive recommendations for change, and the national Moving Forward Nursing Home Quality Coalition is developing workable action plans addressing those recommendations.

U.S. Representatives Lloyd Doggett of Texas and Jan Schakowsky of Illinois led 113 members of Congress in signing a March 13, 2023, letter urging CMS to enact robust nurse-to-patient staffing ratios for nursing facilities this year. The representatives comprehensively describe the need and widespread support for safe nurse staffing ratios, limiting the number of patients on a nurse’s workload, and the need for transparency in Medicare and Medicaid spending on nursing facilities. A February 2022 fact

sheet from the White House states that proposed rules to implement the Biden-Harris administration’s commitment to enact enforceable nurse staffing standards are expected in the spring of 2024.

Urge your Congress members to support and demand passage of the bills listed in the sidebar. We cannot allow this moment to pass. We and our loved ones have waited too long, at too high a cost.

Pending LTC-Related Bills

WISH Act: provide catastrophic long-term care insurance, creating a large insurance pool to reduce reliance on Medicaid. Nursing Home Disclosure Act: improve public disclosure of nursing home medical directors.

Home- and Community-Based Services Access Act: make changes addressing gaps in services when consumers want to age in their own homes.

Linking Investors and Nursing Home Quality Act: bring transparency through annual disclosure of ownership and financial activity of nursing homes.

IMPROVE Nursing Homes Act: provide funding and create a grant program to convert traditional nursing homes into smallhouse nursing homes.

The Elder Justice Reauthorization and Modernization Act of 2021: increase funding for states’ Long-Term Care Ombudsman programs; provide funding for long-term care workforce development; and provide grants and training for community-based organizations.

Essential Caregivers Act of 2021: permit designated essential caregivers to enter long-term care facilities to provide care and support during a public health emergency (to be reintroduced).

The Nursing Home Improvement and Accountability Act of 2021: increase transparency, accountability and oversight in nursing homes; improve staffing; and support innovation in the structure and culture of these facilities (to be reintroduced).

Kathy Bradley is the president of the advocacy nonprofit Our Mother's Voice. For more information visit ourmothersvoice.org.

Know Your Coverage Options With Medicare

Factor in your lifestyle, budget and health to make the right choice

By Caroline Ward

Medicare is a federally funded health insurance program for individuals age 65 and above and for individuals under 65 with certain disabilities. To be eligible, one must be a U.S. citizen or legal resident of five years.

As I meet with people becoming eligible for Medicare, they are often confused by the options available. Basically, you have three options with Medicare coverage:

Option 1: Start with Original Medicare. This includes Part A (hospital and skilled nursing facility coverage) and Part B (doctors and medical coverage). Original Medicare does not include prescription drugs, so you will also need to purchase Part D (prescription drug coverage). NOTE: Part D is optional but highly recommended to avoid a lifetime penalty if you later decide that you want to add prescription drug coverage.

Original Medicare does not include dental, vision or hearing coverage. Additional insurance plans can be purchased to cover these ancillary benefits.

If you want to add more coverage to Original Medicare, consider adding a Medicare Supplement or Medicare Advantage plan.

Option 2: Add a Medicare Supplement to Original Medicare.

A Medicare Supplement (also called Medigap) pays the hospital Part A deductible, most co-pays and all other costs not covered by Original Medicare. In essence, the Medicare Supplement pays the “gap” of expenses not paid by Original Medicare.

Medigap plans do not include prescription drugs, so you will also need to purchase Part D. As with Original Medicare, Part D is optional but highly recommended to avoid a lifetime penalty if you later decide that you want to add prescription drug coverage.

A Medicare Supplement does not include dental, vision or hearing coverage. Additional insurance plans can be pur chased to cover these ancillary benefits. Medicare Supple ments are managed by private insurance companies.

Option 3: Choose a Medicare Advantage plan.

A Medicare Advantage plan combines Part A and Part B, and most plans also include Part D for prescription drug coverage. Key benefits such as dental, vision and hearing coverage are included. Other benefits may include a free gym membership, over-the-counter pharmacy spending allowance, transportation to medical appointments, life alert system and home-delivered meals after hospitalization. Medicare Advantage plans are managed by private insurance companies.

If you are approaching Medicare eligibility, seek out the services of a local insurance agent; at no cost to you, receive help navigating the Medicare maze and making a decision that works best for your health issues, lifestyle and budget.

Caroline Ward is an independent Medicare consultant. Email her at Caroline@AskCaroline.net.

Long-Term Care Insurance isn’t for Sissies

By Carl “Doo Dad” Cease

My May issue article on financing elder care expenses focused on whole life insurance with a long-term care access rider. Its benefits include level premiums throughout the life of the policy and a death benefit that can be left to your beneficiary. And more importantly for our discussion, the policy can be used for elder care expenses.

Long-term care insurance at an elementary level is very simple. In exchange for a monthly premium, the insurance company guarantees you a pot of money. With that pot of money, you’re able to pay for qualifying elder care expenses. Levels of elder care include skilled nursing care, assisted living, home health or even adult day care.

The policies are flexible in paying for the most appropriate level of care needed at the time. Start out with a caregiver coming in to help at home, transition to assisted living and, if needed, transition to skilled care. It all comes out of the same pot of money. The goal is to make sure the pot of money isn’t exhausted while care is still needed.

Varying options among policies include monthly benefits and elimination periods. Respite care benefits are a popular option, as is hospice. Think of them as a buffet you peruse to design your policy. Don’t care for a 180-day elimination period? Choose 90 days. Want to waive the elimination period for home health care? Done.

I can hear you saying, “That sounds great, Carl. Where do I sign up?” Here enters the first problem. There are few insurance companies left that have long-term care policies for sale. Most have exited the market over the last 20 years. The details of why are beyond the scope of this article, but suffice to say they were losing money hand over fist.

Another concern is future premium costs for the insured. Long-term care policies are expensive to begin with, and the carriers are allowed to raise premiums. A policy sold today may stay at the same premium forever. But it might not, and no one likes their insurance premium going up, particularly as one approaches retirement age. History tells us premiums will increase, some to the point of the insured having to drop the coverage before ever using it.

Does that sound completely grim? Take heart! These policies work very well in the right situations.

How would you know what makes the most sense for your situation? Find an advisor who knows what they are doing. That advisor should spend significant time learning in detail about your financial situation, family and community support, current health and how you desire your care to be structured. If that advisor talks about a product or service before they know you as a person, find someone else to work with. It’s too important a decision to leave in the hands of someone you don’t trust.

Why the best-known solution may not be for you

Critical Transitions Wealth Advisors has a proven process to bring clarity and reduce potential mismanagement. As an advisory fiduciary, we offer advice in your family’s best interest in areas such as consolidating assets, investment management, navigating Social Security & Medicare, your role as Power of Attorney & Personal Representative, and planning for a terminal illness or permanent care diagnosis. Together we can create a plan!

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