Last week, we heard from Erin Kershaw of Concierge Care Advisors. This is a group that concerns itself with the inevitabilities that beset the aging. The two main issues concern housing and the management of one’s personal affairs. She stated the sobering fact that. sooner or later, a person will need help. Dementia, illness, or injuries will bring a person to this point. Dementia is extremely prevalent and at times may afflict even the relatively young. This said, what are the options, both for physical care and for the setting of legal and financial matters in order?

The domiciliary levels of care, tailored to the individual situation, are these:

–The home. If it is elected to keep a person at home, it may be feasible if private duty nursing care is in place and if medical care is gotten from the outside. It is to be noted that this is an expensive way to go, probably more so than another type of residence. 

–Retirement and assisted living. This has the advantage of community, a social life, a common dining room, a bus for transportation, and a feeling of security. One must, however, bring about one’s medical care independently. Medicaid is generally not accepted.

–Adult family home. In such a facility, occupancy is limited to six. State guidelines prevail. If money runs out, transition to Medicaid occurs and the resident is not forced to move. These facilities do not accept Medicaid on a person’s arrival.

–Memory care. This is a type of facility that is attached to assisted living. It will not do Medicaid.

–Skilled nursing facility. This is more clinical and has similarities to a hospital. Physical therapy and short-term rehabilitation are offered here. While people rarely would choose such a place in which to spend the rest of their days, some have to. The cost is high. Medicare will not cover this when physical therapy and other modalities can no longer result in progress. 

• The financial aspects involve methods of paying for these levels of care. Such as–
• Savings and other assets
• Pensions
• Medicaid
• Veteran benefits. This is geared to one’s income and whether one has been in actual combat. One who is married to a veteran may receive assistance under certain circumstances. 

It is well to make one’s plans, prior to any crisis. These include–

• Will
• Advance Directive
• Power of attorney, given to one who can make decisions.

The speaker concluded with the matter of “tough conversation” with one needing help or one who makes the decisions for such a person. It entails wishes versus reality. A person’s wishes may be to remain at home, pass assets on to family, and maintain independence. Quite often the reality is that the individual and family are in denial about health care needs. The family cannot provide it. The home is not adequate for safe living.  There will be social isolation. 

And, she finished, correctly, with, “The TV is not your friend.”

Comment:  ‘Tis always the other guy, till ’tis oneself.

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At last week’s meeting, our esteemed member, Dr. Harold Elner, MD, called upon his career as a specialist in urology to give us the basic structure, functions, diseases and remedies for the genito-urinary system. All in the space of 25 minutes or so. And he kept it “clean,” PG-rated at most. President Ryan Hamilton expressed appreciation for Dr. Hal’s educational talk and for his discretely avoiding the really graphic stuff. Here is a sample:

• Regarding prostatic cancer, there is the eponymous “three-legged stool” required for diagnosis, to wit, PSA, digital examination, and biopsy. When it occurs in relatively younger men (40s or 50s) a radical approach is often chosen. At times this can result in incontinence and, frequently, impotence.
• Benign enlargement of the prostate, when it reaches a point wherein one experiences frequency of urination, getting up at night three or more times, and a slow/weak output, surgery had mainly been the treatment. This surgery has most often been through an instrument. More recently, drugs that relax the bladder outlet have come into vogue. Use of these has allowed the deferment or avoidance of surgery.
• Any blood in the urine, in even microscopic amounts, and particularly painless, must be investigated. A physician who does not do this is remiss. There are instances in which patients have been treated for assumed infection when there has lurked a malignancy or an enlarging stone.
• As stated, the treatment for kidney or ureteral stones too large to pass had been open surgery. Enter then the Dornier Company in Germany, those fine folks who gave us the long-range WWII bombers. They were experimenting with shock waves to de-ice the wings of the planes. At times these waves shattered the glass on the instrument panels. It was then thought to use this principle to shatter things that needed shattering. Thus arose the lithotripter, in which shocks generated by a condenser were focused on the stones (aka calculi), pulverizing them. Since then, refinements have made the process less cumbersome. A preferred method is to pass a probe into the ureter and blasting the stone with the laser. Ergo, open surgery for urinary calculi is now only rarely done. Anyone who has experienced the agony of a stone can appreciate the relief afforded by these treatment modalities.
  Generally speaking, a patient in such a situation moves about looking for a comfortable position (there isn’t one). This contrasts with someone who has an event within the abdomen (i.e. acute appendicitis) and who lies very still.

Conclusion and Comment: Sooner or later, everyone meets the urologist.

*The drawings used in this presentation were by the celebrated medical artist, Frank Netter, M.D. Dr. Netter was a graduate of DeWitt Clinton High School, Bronx (preceding the speaker there by about a generation). His artistic talent was such that he left his medical practice to devote full time to these drawings that are known worldwide.

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