“Two Kinds of Hospital Patients: Admitted, and Not”

Over a year ago (June 22, 2012), the New York Times covered the topic of how someone with Medicare can be a patient in the hospital but not be an “admitted patient.” 

They’ve picked up the topic again this week probably because on October 1st a new Medicare policy took effect.  The new policy is:

“When a physician expects a patient’s stay to include at least two midnights, that person is an inpatient whose care is covered under Medicare Part A, which pays for hospitals. If it doesn’t last two midnights, Medicare expects the person to be an outpatient, and Part B, which pays for doctors, takes over.”  Apparently there is unanimity in disliking this new policy, which Johns Hopkins calls the “Cinderella Rule.”

The 2012 article refers to this Medicare publication –

“Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!”

Here’s a link to this week’s article:  (Note that some of the comments are worth checking out)


The New Old Age: Caring and Coping
Two Kinds of Hospital Patients: Admitted, and Not
New York Times
By Paula Span
October 29, 2013, 12:01 pm


Where’s That Advance Care Directive? (NYT, 10-17-13)

Many people have completed advance care directives (healthcare power-of-attorney, living will, POLST, Five Wishes, etc.) but, as this New York Times article points out, they haven’t distributed copies to the right people and they don’t have a copy available when needed.  The article notes that often these ACDs are at lawyers’ offices or in safe deposit boxes.

Between the article and the comments on the article, this advice was given as to whom to distribute copies of your ACDs:

  • primary care physician
  • other physicians including neurologist and cardiologist
  • individuals named as healthcare decision-maker
  • additional family members and friends

The author says:  “The more copies there are in circulation, the better the odds that one will materialize at the hospital when you need it.”

One of the comments had this useful advice from an attorney:  “I also tell clients to enter the names and numbers of their agents/proxies into their cell phones under an entry entited ICE== in case of emergency.  EMTs look for ICE numbers as well.”

Speaking of EMTs…  One local support group member handed his wife’s living will to the EMTs, who came to their home after he dialed 911 as his wife had fallen.  This is not a form that the EMTs can do anything with.  The only form that should be handed to EMTs is the POLST, which stands for Physician Orders for Life-Sustaining Treatment.  For lots of good info on the POLST, see capolst.org.

Other comments contained advice on where to place copies:

  • On the refrigerator door
  • If not on the refrigerator door, then put note on refrigerator door telling EMTs where the copy can be found, maybe near a bed or on the back of a door.
  • “Put a copy of it in the glove box of your automobiles, and ask your named health care agents to do the same.”
  • “If your health care agent is likely to take an airplane to your home destination, ask him/her to put a copy in his/her luggage.”
  • Save copies electronically in various places – Google Drive (and give access to others), Dropbox (and give access to others), on a smartphone, with a service, on a USB drive.

One other worthwhile suggestion — if you are wanting the ACD of a family member, ask them to give you their completed ACD as a Christmas gift.

Here’s a link to the full article:


The New Old Age: Caring and Coping
The New York Times
Where’s That Advance Care Directive?
By Paula Span
October 17, 2013, 6:00 am


My Life as a Caregiver (Dr. Nancy Snyderman, AARP Mag, Oct/Nov 2013)

This short article by Nancy Snyderman, MD — a medical expert on NBC News — was in the recent issue of AARP The Magazine. Here are a few things I picked up from the article:

* She says: “Perhaps the most important lesson I learned in all of this is how little we plan for the inevitable crises — and how much we all need help.”

* “Caregivers tend to patients an average of 20 hours each week, but many would agree that it often feels like more.”

* About half of all caregivers have a full-time job in addition to caregiving responsibilities.

Here’s a link to the article by Dr. Snyderman:


My Life as a Caregiver
‘When my father fell ill, I put my own life and health on hold to save his. It wasn’t easy’
AARP The Magazine,
by Nancy L. Snyderman, M.D.
October/November 2013



Advice About Assisted Living for Aging Relatives (NYT, 10-16-13)

The New York Times ran part one of a question-and-answer article on assisted living and other living arrangements for seniors.  It seems that senior living options are very location-specific so I’m not sure of the value of this general article.  But see what you think!

I did find value in the first commenter’s nine suggestions.  The first commenter, Kay, said she had seen a parent through dementia and three years in seven different care settings.  Her suggestions include:

1. Buy long term care insurance for yourself, now. This kind of care is expensive.

2. Your parent failed to do #1, and also failed to be wealthy? Your options are extremely limited. Examine your state’s Medicaid program carefully. Pay someone to serve as a consultant, if need be.

2a. Is your parent a veteran? This saved our bacon. Our state runs veterans homes, and the tariff at one of these was low enough (I assume with a DoD offset) that my parent could afford it. It took his whole pension, but didn’t impact us. That said, those places were often in distant, rural areas (they were anchors of the local economy, and placed there to be so), and so were hard for us to get to for visiting. Not to mention his friends.

3. Does your aging relative have dementia of some type? Most facilities are designed to care for the physically frail, not the physically OK but mentally frail. Locked units would drive a sane person crazy. With more Boomers aging, hopefully we can find a better solution.

4. Look into any state benefits for the disabled. Our state has a program that provides a caregiver for ADL’s if the recipient is disabled (and probably poor enough). Anything that can keep you in your own home is cheaper.

5. Group homes, if your relative would be happy with that option, are a more affordable and humane choice. (We’re talking a suburban house where each bedroom has a resident, and there are at most two caregivers present. This only works for people with relatively few needs.)

6. Most facilities of any type are heavily populated by women. If your relative is a man, he might totally hate this. Mine did.

7. Even in the best of places (nursing homes especially), staffed by the most loving caregivers, there is no substitute for family. You need to visit as often as possible. Did your relative run out of toothpaste? Is the clothing in his/her closet actually his? This can be a real problem if you live far away.

8. Be prepared emotionally for the disagreements between siblings regarding the care of a parent. This tore our family apart in a way that nothing else even approached. (And, no, it wasn’t about money.)

9. Investigate places in more rural parts of your area. They might be just enough cheaper that you can afford them. But, the drive will be long.

Next Wednesday part two of this article will appear.

Here’s a link to part one of the article:


Ask an Expert
Advice About Assisted Living for Aging Relatives, Part 1
By The New York Times
Published: October 16, 2013


“The Logistics of Death: What to Do When Someone Dies”

Michael Krasny, host of Forum, a radio program on KQED, focused on the logistics of death in a 52-minute long program on Monday, 10-14-13.  One guest was attorney Scott Taylor Smith, author of the new book “When Someone Dies: The Practical Guide to the Logistics of Death.”

Scott Taylor Smith said that as soon as his mother died, the questions began, despite his grief.  First, what mortuary did he intend to use?  Second, the mortuary wanted to know how many death certificates he wanted.  (His suggested answer is take the number of credit cards someone has and multiply by two.  That’s how many death certificates you may need.)

He suggests that you write the obituary and plan the memorial before the person dies.  For his mother, the family wanted to have a celebratory event.  This meant that they waited 6 months after her death before having the celebration.

Scott Taylor Smith talks about conflict in his family over the use of morphine for his mother.

Another guest was Jim Mitchell, an estate lawyer with Coblentz, Patch, Duffy & Bass in San Francisco.  He talked about probate and revocable trusts.  He was asked the downside of setting up a trust; his reply – “attorney’s fees.”  He discussed “permanent” estate tax legislation.

Jim Mitchell talked about two powers of attorney documents:  medical and financial.  He recommends consulting with an attorney on these documents but noted that they are available online.

A couple of the callers mentioned the POLST form.  This form must be signed by someone’s MD.  See capolst.org.

You can find an audio recording here:


I looked over the comments, gleaning one resource and one suggestion:

* everplans.com:  “articles, tips, and checklists to help people with everything from who to call first to how to choose a casket to what the various religious traditions are”

* “Death Certificates are expensive, as well as awkward to obtain. Good News: you can actually request that the various agencies, institutions, et cetera which require presentation of theses documents RETURN them to you (include a SASE with a note. Almost all of them will do so. The really only need to see (and then copy) same. The only exceptions for me were real estate-related (mortgage-holders). Even Social Security returned the certificate. I “recycled” several of them, and in doing, saved myself a lot of money, time and effort.”


Recommended book on DLB/PDD by Dr. Ahlskog – “Patient, Family and Clinician Working Together”

Recently I purchased a book by Eric Ahlskog, MD, PhD, a well-regarded movement disorder specialist at Mayo Rochester.  The book title is “Dementia with Lewy Bodies & Parkinson’s Disease Dementia:  Patient, Family, and Clinician Working Together for Better Outcomes.”

I’ll put it in our support group lending library for someone to borrow at the next support group meeting.  By the way, if you are interested in making an in-kind donation of books to the support group, a non-profit organization, let me know.  Our wish list is long!

I read three chapters today — one on background, one on symptoms/diagnosis, and one on treatment — and skimmed through the rest.  Based on three chapters, I’d say this is a wonderful book.  It contains the precision of a researcher and clinician, but worded in such a way that we laypeople can understand.  I’ve copied a few excerpts below.

There isn’t anything new in the book for me, but I’ve been reading about Lewy body diseases for quite awhile.  There may be new things for you!



Excerpts from:

Dementia with Lewy Bodies & Parkinson’s Disease Dementia:  Patient, Family, and Clinician Working Together for Better Outcomes
by Eric Ahlskog, MD, PhD

“The dementia of both DLB and PDD is due to the Lewy body neurodegenerative process.  However, three other factors also contribute, to varying degrees.  By themselves, these other three factors are not the primary causes of dementia in Lewy conditions but are additive…  One such factor is cerebrovascular disease, which may be…unrecognized; it may also manifest as brain atherosclerosis (hardening of the arteries).  Atherosclerosis of small brain arteries is the reason for leukoaraiosis, which is the white blush present to varying extents on the [MRI] brain scans of older adults.  Treating risk factors for such cerebrovascular disease, especially earlier in life, is wise; however, once dementia is present it may be too late.  Such risk factors include hypertension, diabetes mellitus, elevated cholesterol., smoking, and lack of exercise.”

“A second contributor to dementia, but not a major factor in DLB or PDD, is Alzheimer brain pathology…  Such microscopic changes slowly accumulate with aging in most humans, even those without dementia.  In many older adults they are modest and not sufficient to result in dementia.  However, in a brain already challenged with Lewy neurodegenerative pathology, there is little reserve; a small degree of brain Alzheimer pathology will be additive.  Such changes are noted in many, but not all, with DLB or PDD.”

“Finally, contributing to the dementia of DLB and PDD is normal brain aging.  With passing decades of life our brains shrink, which is very apparent on MRI brain scans in those over age 80 years.  This is primarily due to loss of brain connections as part of the aging process.  Although there is a modest, age-related loss of brain cells (neurons), the primary reason for brain shrinkage is loss of synapses and the connecting neuron circuitry (axon terminals, portion of dendrites).  Fortunately, many older adults without Alzheimer’s or Lewy disease are able to compensate for this age-related brain shrinkage, but it is additive if neurodegenerative disorders are present.”

Why and How Do We Distinguish DLB from PDD?
“PDD starts as Parkinson’s disease, which then progresses to include dementia; those with DLB start out with dementia.  Are these just different ends of a single spectrum?  Are they really the same disorder?  This is an unresolved question.”

“Parkinson’s disease is devoid of intellectual problems when it first develops.  In contrast, cognitive impairment is present at the onset of DLB, sometimes with parkinsonism delayed.  In fact, some people with DLB never experience parkinsonism.”

“How do researchers make the distinction? … An international consensus panel has institute the so-called 1-year rule to separate DLB from PDD. … Obviously, this is a little arbitrary, but such distinctions help researchers clearly define what they are studying.  In the clinic, where clinicians deal with real people and their problems, that distinction is less crucial.”

Fluctuations in Thinking and Alertness
“Unique to these Lewy dementias is the fluctuation of mental clarity.  People with DLB or PDD may be alert and lucid during portions of the day, but inexplicably confused several hours later.  This is a hallmark of DLB and PDD.  Daytime drowsiness may similarly fluctuate like this, although there may be other treatable reasons for sleepiness…  The reason for these fluctuations in mental clarity is unknown.”

Caregiver Resources on Oral Care, Dry Mouth, etc.

Near the end of a New York Times article about the new website toothwisdom.org — which aims to make it easier to find affordable dental care — there’s reference to four good resources for caregivers:

#1 – 17-minute video on providing daily oral care to someone with dementia.  Though this video is for CNAs and RNs working in nursing homes, all caregivers can find value here.  I suggest starting the video at 3:20; the topic is oral care evaluation.  Or start about 6:00, when the topic is brushing someone’s teeth.  Tooth brush handles are modified about 8:40 and again at 12:15.


#2 – blog post on causes and treatment of dry mouth (xerostomia):


#3 – brochure on causes, symptoms and treatment of dry mouth from NYU Dentistry


#4 – complications for oral health in older age:


Several of the people posting comments on the New York Times article mentioned this resource:

#5 – discount dental plans available from various businesses, such as:

Here’s the info on the New York Times article, though the best parts are the references provided above:


The New Old Age: Caring and Coping
The New York Times
A Guide to Affordable Dental Care
By Catherine Saint Louis
October 8, 2013, 11:57 am       


New Way to Pay for Long-Term Care? (sell life insurance policy)

This recent article in the New York Times is titled “A New Way to Pay for Long-Term Care.”  I really think there should be a question mark at the end of that title!  The “new way” is selling your life insurance policy to a company.

A local support group member mentioned that this is what she was doing years ago; her husband had died, she has no children, and she thought this would be a good way to proceed.

I suggest you speak with a certified financial planner or someone qualified before you take action based upon this newspaper article!

Here’s a link to the article:


The New Old Age: Caring and Coping
A New Way to Pay for Long-Term Care
The New York Times
By Paula Span
October 9, 2013, 1:36 pm


New Way to Pay for Long-Term Care? (sell life insurance policy)

This recent article in the New York Times is titled “A New Way to Pay for Long-Term Care.”  I really think there should be a question mark at the end of that title!  The “new way” is selling your life insurance policy to a company.

A local support group member mentioned that this is what she was doing years ago; her husband had died, she has no children, and she thought this would be a good way to proceed.  Though I have an MBA from Wharton, I’m afraid I am inept at managing my own finances.  I advise you to speak with a certified financial planner or someone qualified before you take action based upon this newspaper article!

Here’s a link to the full article:


The New Old Age: Caring and Coping
The New York Times
A New Way to Pay for Long-Term Care
By Paula Span
October 9, 2013, 1:36 pm


CBD Treatment – brief info (Neurology Study-Guide, October 2013)

“Continuum” is a journal published by the American Academy of Neurology.  Its subtitle is “Lifelong Learning in Neurology.”  It’s a study-guide for neurologists.  Every year or maybe every other year they have an issue devoted to movement disorders.  Within that issue, there’s always an article on three parkinsonian syndromes — PSP, MSA, and CBD.  This year’s article has two authors — Dr. Irene Litvan, who was the keynote speaker at our October 2012 atypical parkinsonism symposium, and Dr. David Williams, a rising star in the atypical parkinsonism community.  (Unfortunately for us, Dr. Williams lives in Australia.)

The study-guide is available at no charge online:


Continuum (Minneap Minn). 2013 Oct; 19(5 Movement Disorders): 1189–1212.
Parkinsonian Syndromes
David R. Williams, MD, MBBS, PhD, FRACP and Irene Litvan, MD, FAAN

The CBD-related section of the study-guide has three parts:

#1 – a description of the classic type of CBD.  There are actually five types of CBD.  CBD-CBS is considered the “classic type.”

Video is available of someone with CBD-CBS, the classic type.  Dr. Litvan is heard/seen in this video.  She showed us this same video in October 2012.  There is a case report of the same woman as in this video.  I’d suggest focusing on the case report and the video.  There is also new diagnostic criteria for CBD-CBS.

There is also a short description of the CBD-PSP type.

#2 – a two-sentence “natural history.”  (Sadly we know so little about CBD.)

#3 – treatment paradigm.  Again, this is a very short section.  The key sentences are these:

“The most useful symptomatic therapies are those targeting myoclonus (eg, valproic acid, clonazepam, levetiracetam, and piracetam) and dystonia (eg, botulinum toxin) when they affect the patient’s quality of life. Treatment of dystonia is indicated when the contractures cause pain or impede hygiene.”