Multi-Specialty Teams Help Seniors Manage Diabetes (Part 1 of 2)

A multi-disciplinary medical team of pharmacists, podiatrists, optometrists, ophthalmologists, dentists and dental hygienists best assist seniors in managing their diabetes by addressing medication, foot health, vision impairments, dental loss, and heart conditions, researchers at the U.S. Centers for the Disease Control (CDC) and Prevention and the U.S. National Institutes of Health (NIH) say.

While most of the aforementioned categories of physicians may not have time to take on these different aspects of diabetes outside of their specialties, they may be able to ask questions and provide their senior patients with advice during regular visits, check-ups and exams, the National Diabetes Education Program’s (NDEP) Pharmacy, Podiatry, Optometry and Dental Professionals Work Group of CDC and NIH say.

The joint-federal agency working group releases their annual reference guide titled Working Together To Manage Diabetes: A Guide for Pharmacists, Podiatrists, Optometrists and Dental Professionals to train medical professionals to converse with aging diabetics about treating their condition with insulin, drugs, proper diet, exercise and sleep.

The booklet’s recommendations on how to diagnose and manage pre-diabetes and diabetes are based on clinical work and research by the medical professional trade organization American Diabetes Association (ADA). It and other specialty-based literature and materials are available at

Affected professionals also include primary care, family practice or internal medicine physicians, physician assistants, endocrinologists, certified diabetes educators, nurses, nurse practitioners, registered dietitians, cardiovascular specialists, renologists, neurologists, psychologists, psychiatrists and social workers.

Certified diabetes educators are trained healthcare providers who can counsel and train diabetics about their condition by setting behavioral goals and discussing health issues. A diabetes educator is usually a nurse, dietitian or pharmacist certified to guide and instruct patients about diabetes and self-care.

Diabetes Prevalence and Impact

Deemed severe, common, expensive but able to be controlled, diabetes is considered the sixth leading cause of death in the country and impacts at least 21 million individuals with at least 6.2 million undiagnosed. It costs the nation nearly $200 billion in direct and indirect expenses.

Nationally, diabetes ranks first among all long-term, deadly diseases as the cause of lower limb amputation that is not connected to trauma, first as the cause of acquired blindness and first as the cause of kidney disease ending up in dialysis.

The condition also contributes significantly to heart disease, being its number one cause of death in the country. At least 65 percent of senior diabetics die from heart failure.

Meanwhile, the prevalence of diabetes increases. Federal research shows it has more than tripled in the last 25 years from 5.8 million to the current 21 million, and in some states, over 25 percent of adults are diabetic. Projections will continue to be high. By the year 2050, the number of diabetics is expected to reach 39 million.

With current trends, one out of every three individuals nationwide will contract diabetes in his or his adulthood and may find his or her life span reduced by 10 to 15 years.

There are three forms of diabetes, type 1, type 2 and gestational diabetes. Federal research shows that, as of 2005, about two-thirds of adults nationwide were obese with the body mass index (BMI) of over 25, contributing to the onset of diabetes in this segment of the population.

In fact, the incidence of obesity has jumped by 61 percent since 1991, leaving more than 60 percent of adults overweight. A high body mass index and obesity pose the greatest risks to individuals for developing diabetes.

Type 1 is defined an autoimmune disease that is characterized by the destruction of insulin-producing beta cells. This version of diabetes can take place at any age but most especially in childhood or young adulthood.

Type 1 diabetes patients can develop ketoacidosis, a diabetic complication in which the body releases excess blood acids also known as ketones. Diabetics must take insulin daily whether by injection, insulin pump or inhalation.

Additionally, type 1 diabetics must test their blood sugar several times every day, follow a customized meal plan and take part in physical exercise.

Type 2 diabetes is connected to insulin resistance. The pancreas produces insulin but it is not recognized or used by other body tissues. Patients of this form of diabetes are treated with insulin, drugs or both. Otherwise, the condition can be controlled with an individualized food plan and physical exercise.

The development of type 2 diabetes is multifactorial, with insulin resistance, sedentary lifestyle, advancing age and obesity contributing to this increase.

This version of diabetes hits nearly 10 percent of the country’s population of young adults and double of the senior segment with a high incidence among those who are obese and physically inactive.

Still, the number of type 2 diabetics among children and teens is increasing, a n important concern as the number and intensity of complications grow with age.

Type 2 diabetes affects African Americans, Hispanics, Native Americans, Alaska Natives, Hawaiians or other Pacific Islanders and they are all two times as likely to have the condition as whites of the same age group. Some sectors of the Native American population suffer the highest rates of diabetes in the world.

The third form, gestational diabetes, involves glucose intolerance in women at the time of pregnancy. Gestational diabetes is most likely to take place among African Americans, Hispanics and Native Americans. It also occurs in obese women with a family history of diabetes.

At the time of pregnancy, mothers are treated to have their blood glucose levels stabilized so as to not affect their infants. Afterward, five to 10 percent of gestational diabetics are discovered to have type 2 diabetes. Indeed, women with gestational diabetes harbor a 20 percent to 50 percent risk of contracting diabetes over the next five to 10 years.

Other forms diabetes stem from genetics such as “maturity-onset diabetes of youth,” surgery, drugs, malnourishment, infections and other illnesses. They make up 1 percent to 5 percent of such cases.

Prevention Tools

About 54 million individuals aged 40 to 74 years of age — an age group that makes up 40.1 percent of the country’s population — suffer from pre-diabetes, which endangers them into developing type 2 diabetes.

Without action, pre-diabetics can advance to type 2 by a rate of 10 percent higher every year. They also have a higher risk of heart disease and stroke.

Pre-diabetes, “a condition in which blood glucose levels are higher than” what is considered healthy “but not in the diabetes range,” is described as “impaired fasting glucose (IFG) of 100 to 125 mg/dL or impaired glucose tolerance (IGT) diagnosed by a post 75-gram glucose challenge of 140 to 200 mg/DL.”

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of NIH can assist patients and providers in determining whether they are at risk for pre-diabetes. Federal research identifies three types of prevention: primary prevention to keep diabetes from occurring and secondary prevention to prevent complications in those who are already stricken with diabetes (e.g., prevention of foot disease).

Still, a third version, called tertiary prevention, means avoiding worsening complications such as an amputation from injury to a diseased foot or death.

These three levels of prevention occur because of the high financial and non-financial costs of diabetes. Federal research shows that more than 4,100 individuals per day are diagnosed with diabetes. As a result, 55 lose their sight, 120 undergo renal failure and 230 lose a limb to amputation — daily.

To test for diabetes, medical professionals will perform finger sticks or forms of laboratory testing. To qualify to conduct laboratory testing, professionals must be registered with the Centers for Medicare and Medicaid Services (CMS) under the Clinical Laboratory Improvement Amendment (CLIA) of the law governing the policy and procedures of the federal agency.

The amendment sets quality standards for accuracy, reliability and timeliness of test results no matter what types of tests are performed. Three classes of tests and certification have been set and the categories depend on the level of difficulty and effort of the method used.

It has set up rules for each category of testing calling for quality control and documentation processes. Some states have added more requirements for different laboratory sites or medical professionals. For more information, professionals are asked to consult their state agency and the CMS website at

To help those who already have diabetes, the guide, Working Together To Manage Diabetes: A Guide for Pharmacists, Podiatrists, Optometrists and Dental Professionals, provides detail on the type of drugs that best manage blood sugar, including insulin, as well as blood pressure and cholesterol.

The booklet concentrates on diabetes-related complications affecting foot health, vision, oral care and medication therapy issues. Using clinical graphics, including patient education posters to be hung in a medical office, and four specialty-based prevention brochures, it aims to encourage interdisciplinary medical team work to treat diabetes and make appropriate patient referrals.

Additionally, another booklet, the Working Together Medications Supplement, instructs on how to understand and properly use medications meant to control diabetes and can be used to organize team care. Package inserts or another guide titled the Physicians’ Desk Reference include prescribing information.

The Working Together Medications Supplement guide provides insights for professionals and senior patients on such issues as:

–The different types of insulin and the appropriate times to administer them so as to not conflict with a scheduled procedure;

–The most common symptoms of medication use to help a medical specialist to pinpoint a problem and make an appropriate referral to another specialist;

–Reduction of adverse interactions of drugs prescribed by different specialists;

–Avoidance of accidental overdosing or underdosing by generating awareness of medication names, strengths and dosages, and;

–Making the most of each visit, check-up or exam to teach patients about how to correctly use prescribed drugs and to receive drug use counseling from a primary care physician or pharmacist.

Physicians, specialists and other medical professionals can access the reference guides, which are all free, at the Centers for Disease Control and Prevention’s continuing education website, and fill out an evaluation form and post-test.

Taken together, the guides are meant to help professionals identify the different type of diabetes and to prevent complications; to practice key messages to senior patients about diabetes; to articulate the most pressing concerns about drug therapy, foot health, vision and oral care for diabetics, and; to interpret the outcomes of the Diabetes Prevention Program (DPP).

According to the American Diabetes Association Standards of Medical Care, Diabetes Care reference guide, professionals are required to train senior patients to pay attention to their hemoglobin A1C, a test that shows their average blood glucose over three months (the goal is an A1C of less than 7 or 150 mg/dL), a blood pressure reading at less than 130/80 mm Hg, and a cholesterol count of less than 100 mg/dL.

With such training, senior patients are expected to practice sound self-management habits. They can maintain a customized, healthy meal plan with the help of the dietitian, participate in physical exercise, avoid cigarette smoking with guidance from a certified diabetes educator, and take prescribed drugs properly with counseling from a pharmacist.

Social workers can help coordinate government services for patients, especially seniors, and mental health professionals can assist them with depression and other mental illness issues as they pertain to diabetes.

Resources geared at assisting them can be found at the NDEP’s Better Diabetes Care Web site at

Finding the Time

Pharmacists, podiatrists, optometrists, dentists and dental hygienists may not find time to look at a senior patient’s medications, feet, eyes or teeth, especially if each category of physician feels entrenched in his or her specialty, members of the joint CDC-NIH work group say.

However, specialists are capable of sending direct messages to their senior patients about health problems or issues they have noticed. Instead of opening a statement with wording such as, “You should see someone about that … ,“ a specialist could tell his or her patient that, “I recommend that you … “

For example, a pharmacist does not need to be a podiatrist, an optometrist or ophthalmologist or a dentist or dental hygienist or perform an exam to determine when a senior patient presents with a problem that warrants the attention of another category of specialist, the workgroup members say.

A minute is all that is needed, for example for a pharmacist, to view a senior patient’s foot, mouth or eye to ask some questions about medications, supplies or cigarette use, they say.

By merely mentioning the problem a pharmacist, for instance, may have identified, he or she reinforces the need for prevention once he or she examines the issue before referring the patient to another specialist-colleague, goes the argument of the workgroup.

A pharmacist, podiatrist, optometrist, ophthalmologist, dentist or dental hygienist can support comprehensive diabetic care by going beyond his or her specialty to point out potential issues and then make a referral with an “I recommend … “ statement.

CDC-NIH workgroup members say patients will be grateful to specialists for taking their health and well-being into consideration, setting up a referral system and adopting a comprehensive team-care approach with their professional peers.

Foot Health

Besides podiatrists and as part of a comprehensive diabetes care team, pharmacists, optometrists, ophthalmologists, dentists and dental hygienists and other specialists ought to watch their senior patients for the most common diabetes-related foot issues: neuropathy, vasculopathy, dermatological conditions and musculoskeletal problems.

To assess for peripheral sensory neuropathy or the loss of sensation in the feet, specialists should check for the senior patient’s experience of tingling, burning, numbness or sensation of bugs, crawling on the skin of the feet. Podiatrists seek to detect this foot condition by using an instrument known as the Semmes-Weinstein 5.07 (10 gram) monofilament.

Senior diabetics with neuropathy are nearly two times more likely to suffer from ulcers in the feet than their peers without this condition. For senior diabetics with both neuropathy and foot deformity, the danger of cultivating ulcers is 12 times greater. Still, furthermore, senior diabetics with a history of foot disease, including previous amputations or ulcers, face a worsening risk of up to at least 36 times greater.

The demographics most at risk for lower-extremity ulcers and amputations are members of the male gender, non-Hispanics, African Americans, seniors and diabetics of at least 10 years, having past cigarette use and having a history of poor blood sugar control or heart, eye and kidney complications.

A comprehensive foot exam for diabetics includes evaluating “pulses, sensation, foot biomechanics,” which is defined as foot structure and function, and nails. NDEP medical literature titled Feet Can Last A Lifetime describes how to use this monofilament to conduct a complete foot exam and can be accessed at

Vasculopathy represents the cramping of calf muscles when walking, also known as “charley horse”, which leads to several rest periods bet. The cramping stems from insufficient blood in the area below the knee, caused by the blocking of the arteries, which commonly happens in the lower extremities of senior diabetics.

Nighttime severe cramping and toe aches are known as rest pain and is treated by walking or allowing the feet to hang over the side of the bed. This particular symptom means there is an end-stage blood vessel disorder and tissue ischemia, all of which comes before the onset of diabetic gangrene.

Neuropathy is cited by clinical research as being most responsible for ulceration and related foot complications. However, an inadequate blood supply can also lead to bad ulcer healing and, thus, amputation. Both neuropathy and not enough blood should be factored into a complete diabetic foot exam and care.

Dermatological conditions are exemplified by feet corns and callouses, also hyperkeratotic lesions, which are the result of “elevated mechanical pressure and shearing of the skin.” These conditions come before the “breakdown of skin” and cause “blisters or ulcers.”

Additionally, “surface lacerations and heel fissures or maceration (softening by wetness)” can all result in infection. “Corns, callouses, toenail deformity and bleeding under the nail” may be symptoms of neuropathy. “Fungus infections of skin or nails” become secondary infections that must be treated immediately.

“Musculoskeletal symptoms” in diabetic feet may emerge with “muscle-tendon imbalances” because of motor neuropathy. Such deformities include the hammertoes, bunions, high-arched foot or flatfoot, which raises the possibility for irritation of the foot in the shoe.

A patient’s style of life and his or her family history can determine the status of foot health. Senior diabetics who smoke are four times more likely than smokers without diabetes to acquire lower-extremity vascular disease.

Consuming foods high in fat and sodium and remaining physically inactive can lead to insufficient long-term control of blood glucose and place the patient at risk for diseases of the peripheral nervous system and blood vessels.

Additionally, a family history of illnesses of the blood vessels in the brain and coronary artery disease may mean a greater risk of lower-extremity arterial complications. Foot types or shapes may make a patient more vulnerable to biomechanical deformities that could end in skin breakdown.

Senior patients with neuropathy are highly likely to acquire degenerative arthropathy, also known as Charcot foot, that targets the joints and results in a red, swollen and deformed foot that can be taken for cellulitis. A Charcot foot usually means little to no pain and may progress over weeks to months before a specialist discovers it in a patient.

Radiological imagery may reveal a collapse of joint structure and can be taken for osteomyelitis. Therapy for Charcot foot is a light cast, in the absence of any swelling, and special shoes to correct changed biomechanics. If Charcot foot is not treated, the senior patient’s feet can degenerate into greater deformity, ulcers and, in the end, amputation.

Podiatrists and specialists in general should watch for senior patients who complain that their shoes don’t fit or wear slippers or shoes with portions cut out to adapt to changes in foot shape or limping.

The American Diabetes Association (ADA) and the American Podiatric Medical Association (APMA) take into consideration two forms of risk for developing diabetic foot complications: high risk and low risk.

The symptoms of high risk for developing foot disease include a “loss of protective sensation, absent pedal pulses, foot deformity, a history of foot ulcers and prior amputation.” By sharp contrast, for low risk, none of these symptoms exist.

To prevent low-risk senior patients from advancing to high risk, both professional trade associations, the ADA and the APMA, ask specialists to urge them to control their A1C, or hemoglobin blood sugar levels, blood pressure readings and cholesterol count and to quit smoking for those using cigarettes.

To assist high-risk senior patients, both organizations ask specialists to help patients guard against developing ulcers through self-management training, foot care and using the proper footwear. Light trauma “such as stubbing a toe or stepping on a sharp object” is the event most likely to lead to acquiring ulcers.

As a result, specialists are asked to stress to senior patients and their families the need to take the initiative to clear out walking areas, especially near the bed and the route to the bathroom, and to use night lights to enable a senior patient to see in the dark.

Additionally, high-risk senior patients must know who and when to call about their foot health issues. Same-day emergency calls to a primary care physician or podiatrist will likely be about a puncture wound, ulcer, redness or new foot pain. For less urgent issues such as patients with callouses or thick or ingrown nails, a podiatrist should be phoned and visited within a matter of days.

Nearly 20 percent of senior diabetics who visit their primary care physicians or specialists for check-ups or exams will present a foot health issue. With each visit, their doctors must ask their senior patients to take off their socks and shoes and check both feet for problems.

The likelihood of developing foot ulcers among diabetics is 15 percent. Worse still, the probability of diabetics with kidney complications and undergoing dialysis at risk for foot complications is higher but is treatable.

A podiatrist or other specialists are asked to pose senior diabetics the following questions when probing for foot care problems:

Whether they know how diabetes affects their feet, that diabetes puts them at risk for ulcers, which can result in amputations, and that foot care can prevent this;

Whether they have had a comprehensive foot exam in the past year and, in particular, one by a podiatrist, and a foot inspection by a primary care doctor, and;

How do they care for their feet daily and if their care regimen includes looking and touching for cuts, bruises, puncture wounds, corns or callouses, redness or pus; cleaning the feet’s skin and nails daily; drying in between toes; checking the insides of shoes for materials before wearing them and avoiding walking barefoot at all times.

Specialists can also refer senior diabetic patients to foot care literature from NDEP in English and Spanish at

Research Makes Gastrointestinal Health A Senior Care Priority (Part 2 of 2)

Gastrointestinal Problems

The NCI identifies the most common gastrointestinal problems examined by gastrointestinal specialists or gastroenterologists as constipation, impaction, bowel obstruction, diarrhea, radiation enteritis, gastrointestinal perforation, anthrax, gastroenteritis/colitis, laxative overdose, angiodysplasia of the colon and gastrointestinal bleeding.


Constipation is the slow, uncomfortable and possibly painful movement of dry, hard stool through the large intestine. This condition worsens as more fluid is absorbed and the waste becomes drier and harder.

If waste matter is not removed from the intestine at least once a day to three per day and at least three per week, physicians may diagnose a senior patient with constipation.

A physician assesses for constipation by reviewing the history of a patient’s bowel habits, including distention, gas passage, cramping and rectal fullness, a change in diet and drug use and by conducting occult blood tests and regular physical exams.

A lack of physical activity, a form of disability or social barriers such as the lack of bathroom accessibility, can cause constipation. So, too, can depression and anxiety brought on by cancer treatment or pain, insufficient water or fluid intake and the ingredients of certain pain relievers, though these last two factors can be managed.

To manage constipation, doctors may suggest that patients increase their intake of fiber through fruits, vegetables, whole-grain cereals, breads and bran and water or other fluids.

In fact, research was conducted involving senior patients, including cancer patients, to compare the medical care effectiveness, cost and management of a natural laxative mix of raisins, currants, prunes, figs, dates and prune versus the use of stool softeners, lactulose and other laxatives. The results found the natural laxative mix to be more medically and cost efficient.


By contrast, while constipation is uncomfortable and painful, fecal impaction is dangerous. Impaction is the collection of dry, hard waste matter in the rectum or colon.

Most senior patients with impaction may exhibit circulatory, cardiovascular or respiratory problems more than gastrointestinal issues but the main symptoms are back pain and bladder, urethra and urinary problems, especially frequent urination.

Physicians assess for impaction by asking the patient questions about constipation, using instruments to listen for bowel sounds, examining the abdomen to determine the level of gastrointestinal activity and conducting a rectal exam for the presence of stool in the rectum or colon and an abdominal X-ray for such features as gas passage.

Stool movement around impaction may produce diarrhea and coughing. It may also lead to stool leakage, which comes with nausea, vomiting, abdominal pain and dehydration.

Such a patient may be found in a confused or disoriented state and suffering from fever and high or low blood pressure. If not detected and addressed immediately, impaction may result in death.

The main causes of impaction are opioid medication, a lack of physical exercise or activity, changes in diet, psychiatric illness or abuse of laxatives. In fact, laxative abuse aimed at decreasing constipation is considered the major cause of impaction. Overuse of laxatives makes the colon insensitive to natural reflexes caused by distention.

Doctors treat impaction by watering and softening the stool for removal. They use enemas that incorporate oil retention, tap water or hypertonic phosphates to moisten the bowel and remove the stool. Often, docusate, mineral or olive oil and glycerin suppositories are used.

Occasionally, after an enema is used, a patient may be disimpacted digitally to address the remaining waste matter.

Bowel Obstruction

Large or small bowel obstruction is a partial or complete blockage of the bowel by a method other than constipation and impaction. Eighty percent of bowel obstructions take place in the small intestine while the other 20 percent happens in the colon. A physician may make a determination of obstruction if there is no gas.

An obstruction is classified by three ways: the type of obstruction, the mechanism of obstruction (whether mechanical or nonmechanical) and the part of the bowel in question. Often, it is termed “twisted bowel.”

Total or partial obstruction is typically caused by structural disorders like bowel lesions connected to cancer, post-surgical abdominal problems or hernias. Additionally, a patient with a colostomy, a type of surgery that re-directs a part of the colon to avoid a damaged part of the gastrointestinal tract, are at risk of developing constipation.

There are four types of obstruction: simple in which one site is blocked; closed-loop with blockage in two places; strangulated involving decreasing blood flow, and; incarcerated when the strangulated state is not resolved.

To determine bowel obstruction, physicians may examine a patient for abdominal pain, vomiting and gas or stool passage and may conduct a white blood cell count, electrolyte panel, urinalysis, sepsis, flat or upright abdominal films, enemas and gastrointestinal series.

To treat and manage obstruction, doctors may perform volume resuscitation, elecrolyte imbalances, transfusion support, distended bowel decompression efforts via intestinal tubes, a change in diet and the use of stents.


As diagnosed, diarrhea is an unhealthy increase in stool liquid and frequency of passage of more than three instances of waste matter from the intestine in a 24-hour period. It can span more than four days but less than two weeks. While considered less prevalent than constipation, diarrhea is considered chronic if it lasts more than two months.

Increasingly, the process of cancer care, especially radiation therapy and the stress and anxiety caused, antibiotic therapy, bone marrow transplants or gastrointestinal surgery, are among the main causes of diarrhea and the results can be physically and emotionally damaging.

Diarrhea can change a senior patient’s diet, prompt dehydration, cause electrolyte imbalance, stop function, induce fatigue, affect skin health, restrict physical activity and can be dangerous.

To manage diarrhea, physicians may treat such conditions as impaction; change the laxative therapy in use and the diet of the patient in question for low-fiber, mineral-rich foods that don’t upset the digestive tract; introduce opioid and aspirin use, and; increase liquid intake of water, broths, weak teas, caffeine-free soft drinks, clear juices and gelatin.

Radiation Enteritis

Radiation enteritis is a disorder of the large and small bowels that occurs during and after a session of radiation therapy to the abdomen, pelvis or rectum. The large and small bowels are vulnerable to radiation meant to treat cancer. While radiation dosages can effectively control cancerous tumors, normal tissues can be damaged in the process.

To assess radiation enteritis, physicians may seek out acute signs of injury to the digestive tract after the first session of radiation therapy and up to eight weeks later though some symptoms may present after many months or years. The signs include nausea, vomiting, abdominal cramping and pain, weight loss, and watery diarrhea.

The incidence of radiation enteritis may involve the following factors: dosage of therapy; tumor size and extent; the volume of the bowel treated; other symptoms and illnesses experienced by the patient; the malfunction of the digestive tract in terms of the absorption of fat, lactose, bile salts and vitamin B12; the level of pain felt by the patient; the nature of accompanying discharge, and; the presence of blood in the tract.

To manage enteritis, doctors will consider the level of diarrhea, dehydration, lack of absorption of nutrients and pain and discomfort experienced; attempt to address these with medicine such as brand-name Kaopectate and Immodium liquid formulas, opioids, steroid foams and replacement enzymes; changes in diet, including the use of lactase, fish, poultry and meat, fruit, white bread and toast, pasta, potatoes, vegetables and dairy products; bowel surgery, and; physical rest.

Gastrointestinal Perforation

Gastrointestinal perforations are holes in the wall of the stomach, small intestine, large bowel or gall bladder and a matter of medical emergency. Perforations are generally caused by illnesses such as appendicitis, diverticulitis, ulcer disease, gallstones or gallbladder infection and inflammatory bowel disease, including Crohn’s disease and ulcerative colitis. They lead to leakage of intestinal substances into the abdomen, leading to a form of inflammation called peritonitis.


Anthrax, an infectious disease caused by the bacteria called bacillus anthracis, involves the skin, the gastrointestinal tract or the lungs. This illness, which affects hoofed animals such as sheep and goats, inflicts humans who come into contact with them.
Typically, farm workers, veterinarians and tannery and wool workers tend to be patients. They may contract cutaneous anthrax through a cut or scrape on the skin, inhalation anthrax through the lungs with anthrax spores and gastrointestinal anthrax through anthrax-tainted meat.


Gastroenteritis/colitis, an inflammation of the stomach or intestine due to infection by the virus cytomegalovirus (CMV), is caused by a herpes-type virus related to one that leads to the onset of chickenpox.

Throughout their lives, most people confront the virus by saliva, urine, respiratory droplets, sexual contact and blood transfusions. It creates mild or no symptoms in healthy individuals.

However, some individuals with weak immune systems can develop CMV infections, including patients receiving chemotherapy for cancer, treatment for AIDS and immune-suppressing drugs after an bone marrow or organ transplant.

Those with strong immune systems may acquire CMV infections from a physical injury, kidney failure or infection.

Laxative Overdose

Laxative overdose can take place when an individual accidentally or intentionally ingests more than the normal or recommended amount of drugs. Some overdoses in children are by accident but adults primarily abuse laxatives to lose weight.

The toxic ingredients in the most abused laxatives are bisacodyl (Dulcolax), carboxymethylcellulose, castor oil, docusate, glycerin, lactulose, magnesium citrate, magnesium hydroxide, magnesium oxide, magnesium sulfate, malt soup extract, methylcellulose, milk of magnesia, mineral oil, potassium bitartrate and sodium bicarbonate, psyllium, psyllium hydrophilic mucilloid, senna and sodium phosphate.

Angiodysplasia of the Colon

Angiodysplasia of the colon, which involves enlarged and fragile blood vessels in the colon that result in bleeding in the gastrointestinal tract, primarily affects senior patients. It relates to the aging and degeneration of the blood vessels.

Research is still determining the cause of this illness. The greatest cause are normal spasms of the colon that enlarge blood vessels in the gastrointestinal tract.

With severe swelling, a small route develops between a very small artery and vein, which is called an arteriovenous fistula. It is in that portion of the colon wall that a senior patient may experience bleeding.

Angiodysplasia of the colon is not connected to the diseases of the blood vessels, cancer and diverticulosis, another condition of intestinal bleeding in senior patients.

Gastrointestinal Bleeding

Gastrointestinal bleeding refers to bleeding that starts in the upper part of the small intestine to include the small and large bowels in the digestive tract, which starts from the mouth and ends with the anus.

The extent of bleeding ranges from miniscule that can only be detected by laboratory testing to massive and it may indicate serious illness. Long-term microscopic bleeding can mean anemia. Severe massive bleeding can result in hypovolemia, shock and death.

The bleeding can take place at any age from the time of birth onward. The level and location of bleeding dictates what type of tests will be conducted to find the cause. Once bleeding is detected, a number of treatments are available to stem it.

Causes of gastrointestinal bleeding include anal fissure, aorto-enteric fistula, arterio-venous growth, diverticulum, cancer of the small intestine, colon cancer, cow’s milk allergy, Crohn’s disease, duodenal ulcer, dysentery, esophagitis, gastric ulcer, hemorrhoids, intestinal polyps, intestinal obstruction, intestinal vasculitis, nosebleed, portal hypertensive gastropathy, radiation injury to the bowel, stomach cancer and ulcerative colitis.

Foodborne Illnesses

With age, the immune system gradually ceases to function, leading to a decrease in the level of disease-fighting cells and an increased risk of infections. Exacerbating this is the frequency of surgeries by senior patients, which further compromises the body’s ability to ward off infections.

This makes it easier for foodborne illnesses to take hold, James L. Smith, a microbiologist with the U.S. Department of Agriculture concluded in his research.

Smith arrived at this finding after reviewing data from foodborne illnesses at nursing homes, conducting regular physical exams, studying the immune and digestive systems of seniors and looking at the importance of long-term exercise in strengthening the immune system.

Additionally, with aging, inflammation of the lining of the stomach and a drop in stomach acid takes place. The stomach is instrumental in restricting the amount of bacteria in the small intestine so that a decrease in stomach acids raises the danger of infection if it is digested with food or liquid.

Worsening this condition is the deceleration of the digestive process, enabling the spread of bacteria, fungi and viruses in the gut and the development of poison.

Malnutrition is connected to foodborne illness in that it leads to more infections and takes place with seniors in part because of a decrease in the pleasure of eating, the use of various medicines, digestive illnesses, nondigestive diseases, physical disabilities or depression, all of which may lead to a loss of appetite. Sound nutrition is key to keeping a healthy immune system.

Symptoms of foodborne illness include diarrhea, abdominal cramping, fever, blood or pus in the stools, headache, vomiting and severe exhaustion. This depends on the type of bacteria involved and the sum of toxins digested.

The symptoms can present themselves a half-hour after eating or may not arrive for days or weeks. They may start in a day or two but can stay as long as a week to 10 days. In healthy individuals, foodborne illnesses don’t last long and are not dangerous but they can be both lengthy and lethal in seniors.

In the case of foodborne illness, senior patients or their families must act immediately, Smith says in his research. Seniors must store and mark a portion of the suspect food, recording the food type, the date, the time consumed and the moment the symptoms began.

They must obtain treatment, call their local jurisdictional health department if they digested the food at a large event, from a restaurant or food facility and contact the Food and Drug Administration’s (FDA) consumer food information line if they have questions, he says.

Senior patients must also avoid food poisoning in the future by removing uncooked foods from their diets. Their physicians advise them to steer clear of raw fin fish and shellfish, including oysters, clams, mussels and scallops; unpasteurized or untreated milk or cheese or fruit or vegetable juices; soft cheese such as feta, Brie, Camembert, blue-veined and Mexican-style cheese; raw or uncooked egg or egg products such as salad dressings, cookie or cake batter, sauces and egg nog; raw meat or poultry, and; or raw alfalfa sprouts.

Most fruit or vegetable juices in the nation — amounting to 98 percent — have been treated to eliminate bacteria. The FDA requires companies to place warnings on their products.

Natural Foods, Herbal Remedies for Gastrointestinal Health

Aside from the aforementioned treatments and modes of management for gastrointestinal illnesses as constipation, impaction, bowel obstruction, diarrhea, radiation enteritis, gastrointestinal perforation, anthrax, gastroenteritis/colitis, laxative overdose, angiodysplasia of the colon and gastrointestinal bleeding, a variety of natural foods and herbal remedies exist to treat these conditions.

To respond to these diseases, physicians also recommend the use of chamomile tea, green tea, high-fiber flaxseeds, oats, omega-3s, flax oil, ginger, milk thistle, psyllium, saw palmetto, high-fiber hot peppers, onions, sweet red bell peppers, rice, barley, cabbage, beets, carrots, Brussels sprouts, cauliflower and water.

Chamomile tea has and still remains a remedy for relaxation, to cure insomnia and to soothe an aching stomach. Being researched for its antioxidant, antispasmodic and antiseptic properties, it has been used to treat skin irritation, intestinal cramps and wracked nerves. In tea form, chamomile is drunk three to four times daily to eliminate gastrointestinal upset.

Flaxseeds contain protein, dietary fiber and omega-3 fats and can be found in breads and cereals. Flaxseed oil is a rich source of lignans, a plant compound with hormone-like effects on the body, and omega-3 alpha-linolenic acid, a fatty acid that makes up 55 percent of its oil and is anti-inflammatory and boosts the immune system.

Omega-3s and lignans cut back on the risk of certain types of cancer such as breast, colon, prostate and uterus. Physicians recommend grinding the flaxseeds into a coffee grinder before placing them on bread, pancakes or muffin batters. The flax oil also are used as a supplement and can be placed in salads.

Ginger has long been used as a digestive aid as it enables the secretion of digestive juices in the stomach. Research also finds that ginger is effective in treating nausea, especially from motion or sea sickness and from surgery.

The most natural means of using ginger is to make infusions from grated or sliced ginger root though dosage isn’t calculated. For powdered root, the dosage of ginger is 150 milligrams to 1 gram in capsule several times a day.

It can also be obtained as candied or crystallized ginger at gourmet or Asian markets. A one-inch square is equal to one 500-mg capsule.

However, ginger is not recommended for individuals enduring chemotherapy if their blood cell count is low as it functions as a blood thinner and could place a senior patient at risk for internal bleeding.

Green tea is also useful as an herb to hydrate patients and contains antioxidants that defend against bacteria, which is important as dehydration can lead to constipation. Aside from teas, senior patients are also urged to drink plenty of fluids, particularly water.

Milk thistle, because of its active ingredient silymarin, can guard liver cells against poisons, including medications, viruses and radiation. In fact, it fights inflammation and disease caused by alcoholism, toxins and poisonous mushrooms and can help a liver reconstruct with no side effects.

Diabetics are asked to speak with their physicians about watching their blood sugar while taking milk thistle. A normal dosage amounts to 140 milligrams in a capsule two to three times per day.

Psyllium contains soluble fiber through the dried husks of its seeds. It lowers blood cholesterol and functions as a laxative on an over-the-counter basis. It is also present in some cereals. The FDA approved health claims on cereals containing psyllium.

The agency mandates that each product contain at least 1.7 grams of fiber per serving. Senior patients must drink plenty of water and other drinks when eating psyllium-rich cereals or it can lead to gastrointestinal blockage.

Saw palmetto serves as an inflammatory agent but it also offers relief to men suffering from benign prostatic hyperplasia, or BPH, or the slow but gradual growth of the prostate gland. Daily dosing amounts to 160 milligrams twice. The herb also works well with others such as nettle root and pumpkin seed extract without serious side effects.

Some processed medicines used by senior patients can be used with herbs. Some blood thinners and anti-clotting agents can work with Asian ginseng, dong quai, ginkgo, ginger, feverfew and garlic. However, heart drugs like digoxin produce negative interactions when mixed with Asian ginseng or St. John’s wort.

As a result, senior patients must follow instructions when dosing herbals. Researchers ask seniors over the age of 70 to take about 80 percent of the recommended adult dosage of any herbal preparation. Seniors who are frail or cannot take some drugs should begin with half the recommended dosage of medicines.

Some foods have been billed as colon cleaners when eaten raw. These include hot peppers, onions and sweet peppers. Oats join flaxseeds as being highest in soluble and insoluble fiber. Other foods that also known to cleanse the digestive tract include barley, beets, Brussels, cabbage, carrots, cauliflower and watermelon.


Altshuler, Larry, M.D., and Connors, Martha Schindler, “Seniors and Health,” Gastrointestinal Health Program,

American Accreditation Healthcare Commission,

American College of Gastroenterology,

American Gastroenterology Association,

Gastrointestinal Bleeding,

“Gastrointestinal Complications: Supportive Care – Health Professional Information,” National Cancer Institute,

“Gastrointestinal Health in Seniors,”

International Foundation for Functional Gastrointestinal Disorders (IFFGD),

“Keys To Gastrointestinal Health,”

Liver Foundation,

National Digestive Diseases Information Clearinghouse,

Research Makes Gastrointestinal Health A Senior Care Priority (Part 1 of 2)

Research on newer long-term illness issues, personal habits and socioeconomic trends are prompting senior care facilities to make gastrointestinal health one of its top medical concerns, healthcare providers, federal biological science investigators and medical policymakers say.

Documented key trends factoring into the decisions of senior long-term care and short-term care facilities to prioritize gastrointestinal health include the aging of the Baby Boomers, past and present drug abuse, alcoholism and cigarette smoking, the onset of cancer and other deadly diseases, environmental pollution, the use of bottled water, poor eating, sleeping and exercise habits and a struggling economy.

All impact the health of the digestive tract, research reveals, as aging in general without intervention from a proper diet, obtaining enough sleep and practicing physical exercise places gastrointestinal health in decline.

Namely, abuse of certain categories of drugs such as heroin cause constipation. Alcoholism undermines the function of the liver. Smoking, environmental pollution and sometimes contaminated bottled water can lead to heartburn, gastroesophageal reflux disease (GERD), peptic ulcers, liver disease, Crohn’s disease, colon polyps, pancreatitis and gallstones.

Radiation and other therapies to treat cancer causes gastrointestinal problems. An economic crisis is likely to negatively affect an individual’s eating, sleeping and exercise routines and, thus, affect gastrointestinal health, which is dependent on them.

Research by federal agencies such as the National Cancer Institute (NCI), the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK), the Food and Drug Administration (FDA) and professional trade associations such as the Liver Foundation, the American Accreditation Healthcare Commission, the American College of Gastroenterology, the American Gastroenterology Association, and the International Foundation for Functional Gastrointestinal Disorders connects the importance of the soundness of the gastrointestinal tract to overall physical and mental health.

With the outpouring of research on the total health of seniors and gastrointestinal illness over the years, senior care facilities have begun to collaborate more with nutritionists/dietitians, gastrointestinal specialists/gastroenterologists, surgeons, critical care nurses, activities directors, exercise specialists, physical therapists, occupational therapists, message therapists, medical assistants and radiologists to treat and rehabilitate their patients.

The digestive tract includes the mouth, teeth, esophagus, stomach, small and large intestines, rectum, anus, liver, pancreas and gallbladder. Care providers, researchers and policymakers say keeping the tract healthy is vital to good health, which means that each of these components must work properly.

Food is digested before it enters the small intestines where much of the process takes place between the enzymes in saliva and the stomach. More enzymes are made in the small intestines and pancreas. The remainder goes into the large intestine or the colon. Water is purged from what has not been digested.

However, with enzymes decreasing with age, digestion slows down as does, also, the body’s ability to take in nutrients. When this occurs, seniors start to lose benign bacteria, which leads to overuse of the liver and kidneys and courts a wide range of illnesses.

Symptoms of a deteriorating digestive tract include bloating, indigestion and constipation. As conditions worsen, so do the symptoms. Still, a malfunctioning tract can recover with proper nutrition. Enzymes to aid digestion can be bought in supplements to counteract bloating, indigestion and constipation.

Senior Care Concerns

In hospitals and senior care facilities, leadership-level dietitians advise directors of the nutrition department on management and development of clinical services and supervisors of the gastrointestinal surgery and critical care department on delivery, practice and design. These dietitians are expected to have extensive clinical nutritional experience and knowledge of gastrointestinal surgery and critical care.

In the case of seniors, they are aware that this cohort of patients face a unique set of health problems. Dietitians understand that the bodies of seniors differ from that of others and they are more vulnerable to a variety of illnesses and their attitudes towards health care are different as well.

Aging causes patients to change in body weight and composition as both men and women weigh more as they transition from young adult to middle age to senior adulthood. By their 70s, they start to lose weight. As they age, the bodies of seniors regulate blood pressure, body temperature and fluids less efficiently.

Illnesses in seniors can interrupt cell production. For instance, Alzheimer’s disease can lead to the early death of brain cells and Parkinson’s disease can eliminate an excessive number of nerve cells. By comparison, cancer delays cell death and enables cancer cells to proliferate.

The sum of these changes affect how a senior lives, the amount and the type of physical exercise he or she conducts as well as his or her health care needs.

Aside from the fact that seniors present a specific set of health concerns, no single aging adult has the same problems. No two seniors age at the same rate. Additionally, even within one senior, not all body systems changes are entirely synchronized.

Seniors process medicines, whether herbal or pharmaceutical, differently than young and middle-aged adults.

Seniors weigh less and have more body fat than they have muscle. As the percentage of body fat increases, the bodies of seniors metabolize drugs and other substances in fatty tissue, which means that these elements stay in their bodies longer and may be more stronger than similar medications in the bodies of young and middle-aged adults.

These medications collect in the bodies of seniors because their kidneys don’t function as effectively as they did when they were younger adults. As a result, for example, nonsteroidal anti-inflammatory drugs, also known as NSAIDs, are more at risk of causing gastrointestinal bleeding and kidney trouble in seniors than in young or middle-aged adults.
Gastrointestinal Health

Especially after a gastrointestinal surgical procedure or therapy, dietitians provide senior patients with advice about improving their health. While a variety of reasons exist for poor gastrointestinal health, food is the main one.

As a result, dietitians recommend that seniors prevent a range of digestive diseases, including gastrointestinal ones, by eating properly. This means eating a balanced diet of protein, carbohydrates and fats, fresh foods and fiber-rich fruits and vegetables.

A balanced diet clears the intestines, improves bowel movements and decreases constipation. Whole wheat carbohydrates are more fiber-rich than white-flour-based ones.

Seniors are encouraged to consume five portions of fruit and vegetables per day as part of the recommended daily intake with research revealing that this habit guards against life-threatening illnesses such as cancer and maintains a healthy digestive tract.

They are advised to drink fresh and uncontaminated water, specifically two liters, which does not include coffee, tea or carbonated drinks, to stay hydrated and flush out poisons. Two liters equals six glasses daily. Habitual coffee drinkers are asked to remember to drink a glass of water after each cup as coffee has a dehydrating effect on the body.

In an age of national fracking and offshore oil and gas drilling, private home walls tainted by lead paint, radon gas seeping underground, carbon monoxide in homes and garages and electromagnetic waves emanating from nearby electrical poles and generators and other forms of environmental pollution, activities such as drinking safe, purified water becomes more critical to gastrointestinal health.

Tainted water contains bacteria, which may damage the intestines and destroy the digestive system, leading to vomiting and diarrhea.

Additionally, dietitians ask senior patients to steer clear of spicy foods. Extra spices cause high acidity and alkaline content in the intestines, kidney problems requiring dialysis and severe burning.

High acidity can be halted by consuming such foods sparingly, keeping the blood stream at a pH of 7.4 and using liver salts. For similar reasons, seniors are asked to avoid sour foods.

They are cautioned to eat light meals every two hours or to generally eat little but often and to space meals apart daily. Eating a large meal within hours of sleep for the night should be avoided.

Such practices, dietitians say, improve gastrointestinal health by decreasing the burden on the liver and the small intestine from which the blood supply declines and absorption of the nutrients from large amounts of food is made more difficult.

Seniors are also recommended to shy away from foods containing high fat, including deep-fried foods, and to adopt a low-fat diet instead. Avoiding high fat in the diet, dietitians say, prevents the development of gall stones.

Patients are told to cease smoking and drinking excess alcohol, as both or either lead to the formation of small sores in the stomach known as ulcers, compromising gastrointestinal health.

While seniors are prescribed a cocktail of painkillers and anti-inflammatory medication, they are instructed to avoid excess as these, too, lead to stomach ulcers.

Seniors are also advised to stop eating foods that cause allergies and this habit will lead to sounder gastrointestinal health. Symptoms include vomiting, itchy spots on the skin and reddishness around the mouth.

They are asked to take part in a moderate amount of daily exercise, especially those related to the abdomen, yoga or relaxation through message therapy as these are the means of ensuring sound gastrointestinal health and avoiding mental stress. Mental stress leads to gastrointestinal illness, particularly acidity in the stomach and ulcers.

Swimming is ideal as a form of exercise because it not only keeps a patient fit but also tones all the major muscle groups of the body.

Dietitians say sufficient hours of sleep and sleeping at the same time every night also leads to optimal gastrointestinal health as insufficient sleep leads to depression, which triggers unsoundness eating habits that compromise gastrointestinal health.

Gastrointestinal Exams, Programs

Physicians also recommend that seniors, especially those with gastrointestinal problems, participate in specific radiological health programs that include esophageal and anorectal manometry, pelvic muscle retraining, also known as biofeedback, and defecography.

The NCI and the American College of Gastroenterology report that colon and rectum cancers are the fourth most commonly diagnosed cancers and are second among cancer deaths nationally. Screening for colorectal cancer is regularly permitted by most insurers for patients aged 50 years or older and patients with family histories of cancer.

Some common gastrointestinal exams include colonoscopy, liver biopsy, paracentesis, esophagogastroduodenoscopy (EGD), endoscopic retrograde cholangiopancretography (ERCP), endoscopic ultrasound, and percutaneous endoscopic gastrostromy (PEG). Pulmonary tests include bronchoscopy, thoracentesis, bracheotherapy and tracheostomy. Other programs include photodynamic therapy.

Symptoms that warrant a esophageal motility study (EMS) include heart burn, difficulty swallowing, unexplained chest pain, pre-operative evaluation, anti-reflux surgery and diagnostic tool to identify scleroderma, achalasia and nutcracker esophagus.
Conditions that qualify for 24-hour pH monitoring include heart burn, difficulty swallowing, unexplained chest pain, chronic cough and hoarseness.

Problems that satisfy the need for anorectal motility with electromyography (ARM w/EMG) include evaluation of fecal incontinence, chronic constipation, evaluation of rectal pain, retraining on incontinence, pre-operative evaluation, rectal surgery and anal surgery.

To undergo radiological defecography, senior patients must present with the symptoms of prolapsed rectum, intussusception and enterocele. To receive pelvic muscle retraining, patients must exhibit symptoms of fecal incontinence, chronic constipation, difficult evacuation and anal pain.

Physicians also steer senior patients, who experience bleeding, pain, swallowing difficulties and a change in bowel movements, in the direction of endoscopy services that include non-invasive gastrointestinal and pulmonary procedures that last an hour to three hours on an outpatient basis.

Endoscopy involves examining inside the human body with an endoscope, a flexible tube holding a small camera. The type of endoscope used is named for the organs of the body they are meant to examine such as an arthroscope for the joints, a bronchoscope for the lungs, cystoscope for the bladder and a laparoscope for the abdomen.

A gastrointestinal endoscope is inserted through the mouth or anus or rectum and an ultrasound probe can be added to the endoscope, thus called an endoscopic ultrasound.

Small instruments can be used to take samples of possibly diseased tissues. Probes that pertain to the gastrointestinal tract include colonoscopy for colon polyps or colon cancer, EGD or esophagogastroduodenoscopy, enteroscopy and sigmoidoscopy. A patient may be asked to clear out his or her large intestine by enemas and laxatives to prepare for these tests.

For senior patients suffering from diarrhea, physicians may may also order fecal smears, a lab test to inspect a stool sample for bacteria, fungi, viruses or other type of microorganisms that start illnesses in the gastrointestinal tract.

There are multiple ways to collect the sample. One is to capture it in plastic wrap in a washroom and keep it in a clean container in the doctor’s office. Once the physician receives the results of the lab test, he or she can prescribe the most appropriate antibiotic treatment.

Doctors can also direct senior patients to take a rectal culture, a lab test to determine the type of microorganisms that cause gastrointestinal illnesses. With this type of test, a cotton swab is placed in the rectum, turned around and retrieved. A smear is used to grow bacteria or other organisms to observe the culture for growth.

The culture may be carried out in a hospital or nursing home to test a senior patient for vancomycin-resistant enterococcus or VRE in their intestine, a highly communicable disease.

Gastrointestinal Gas

Gastrointestinal gas is defined as flatus or gas eliminated by burping or passing through the rectum. Research finds that individuals produce a normal quota of about one to three pints a day and experience flatulence 14 times a day though some believe they release too much.

The gas is made mostly of odorless substances, carbon dioxide, nitrogen, hydrogen and oftentimes methane. Foods containing carbohydrates cause gas while foods with fats and protein cause little.

The unpleasant scent stems from bacteria in the large intestine that emit gases containing sulfur. The gas comes from swallowed air and the breakdown of undigested foods by benign bacteria in the large intestine.

Air swallowed by a person is also known as aerophagia. Any person can swallow air when eating and drinking. Still, eating and drinking quickly, chewing gum, drinking with a straw, smoking and wearing loose dentures can cause some individuals to breathe in more.

Symptoms of gas include belching, flatulence and abdominal bloating and pain. Crucial factors are likely how much gas the body eliminates and an individual’s sensitivity to gas in the large intestine.

However, large amounts of flatus may signal an abnormality in which the intestine absorbs nutrients, especially if diarrhea or weight loss is present.

While eliminating gas is a healthy, daily digestive process, physicians recommend the omission of certain foods, including high-fat ones, from a patient’s diet to cut down on bloating and discomfort. Scaling back enables the stomach to empty more quickly, letting gas move onto the small intestine.

Gas-emitting foods include broccoli, baked beans, beer, brussels sprouts, cabbage, carbonated drinks, cauliflower, chewing gums, citrus fruits, corn, eggs, greens, milk products, oats, onions, potatoes, red wine and wheat. Doctors also recommend the start of a lactose-free diet to cut down on human gas emissions.

Enzymes such as lactase supplements aid digestion of carbohydrates and empower individuals to eat foods that produce gas. For example, the enzyme product Beano cuts down on gas production connected with baked beans.

Decreasing the amount of air swallowed or aerophagia is also presented as a solution. Aerophagia is associated with excess salivation and many physicians recommend avoiding such habits as too much gum chewing or smoking. They also seek to treat such digestive conditions as peptic ulcer, which may lead to hypersalivation or nausea.

A Conflict of Interest In Independent Pharmacy Consulting

Independent pharmacies that both dispense medications and provide consulting services to long-term care facilities at the same time, present a conflict of interest and may land themselves and the facilities in trouble, the U.S. Centers for Medicare and Medicaid (CMS) and other federal agencies say.

It is important for third-party pharmacies to provide consulting services without dispensing drugs so as to bring greater accountability, transparency and competence to medication choice, administration and overall business activities to satisfy state and federal inspection and review requirements, the agencies add.

Research from the U.S. Department of Health and Human Services, with the Agency on Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC), finds that the Baby Boomer generation continues to age while the number of seniors over 85 will increase by 90 percent over the space of 20 years — with a total elderly population of 34 million.

Third-party independent pharmacies are increasingly serving the prescription needs of long-term and short-term care patients in those facilities, especially seniors.

With such an aging segment of the nation in need of medical care, pharmacies have grown instrumental in meeting their treatment needs and decreasing the costs to the facilities caring for them.

However, the CMS, federal regulators and policymakers say their daily business undertakings have raised issues of integrity. Some pharmacies who both distribute drugs and advise medical facilities have been reported to look out for their own best interests, especially in terms of profit-making, rather than root out the flaws or errors in a client’s medication policies and practices.

This compromises the quality of drugs, the appropriateness of their administration and medical outcomes for their patients, pointing to point a need for independent pharmacies to provide consultation without distributing drugs, they conclude.

Federal laws, Regulations

The Affordable Care Act of 2012 mandates that a long-term care facility carry out the recommendations of a third-party consultant pharmacist, including advice concerning drug formularies.

While the law recognizes the importance of recommendations made by a third-party consultant pharmacist to a long-term care facility, the nursing staff employed there are not imposed upon to execute these directives without inspections from a state agency.

Still, a long-term care consultant pharmacist’s enforcement of a drug formulary influences the facility’s negotiation of a drug manufacturer’s rebates.

Additionally, a number of states make exceptions to the responsibilities of long-term care consultant pharmacists.

For example, in Colorado, consultant pharmacists are expected to fulfill the tasks of legal compounding, evaluate the implementation of policies of the state’s Pharmacy Advisory Committee and publish quarterly reports to the committee on the status of pharmacy activity.

Under Idaho law, consultant pharmacists must supervise services when their employer-nursing facilities use more than one manufacturer of drugs. Such pharmacists in Mississippi must attend board-approved workshops to be trained in their duties.

In Oklahoma, they must assist with drug destruction and converse with the staff of their employer-facilities about policies and procedures related to destroying medications.

Overall, most states throughout the country are expected to authorize third-party consultant pharmacists to provide these aforementioned services to the employing long-term care facilities.

Still, nursing homes and skilled nursing facilities have stand-alone agreements that spell out duties for pharmacy dispensing services and consultant pharmacy services. For instance, New Jersey is the only one calling for a separation of such services so that the consultant pharmacist cannot work for the dispensing pharmacy.

In October 2011, CMS released a draft regulation that called for more independence on the part of third-party pharmacists employed by consultant pharmacies to avoid the conflict of interests it found when it investigated such practices tied to long-term care facilities, serving mostly seniors.

Titled “Medicare Program; Proposed Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2013 and Other Proposed Changes; Considering Changes to the Conditions of Participation for Long Term Care Facilities,” the draft rule focused on the agency’s concern with pharmaceutical manufacturers paying third-party long-term care pharmacies to have their staff consultant pharmacists urge doctors to prescribe their drugs to facility patients.

Consequently, CMS questioned the ability of third-party consultant pharmacists to review drug regimens impartially and to avoid compromising the quality of such evaluations and, thus, endangering the health and safety of patients. The agency also raised issues about long-term care pharmacists maintaining ties with pharmaceutical manufacturers.

Through its investigations of industry, CMS revealed that third-party, long-term care pharmacies outsource consultant pharmacists to nursing homes for compensation below the expenses of such pharmacies and below market value.

As a result of its findings, the agency stated that it pondered calling for long-term care facilities to hire independent pharmacists. By definition, an “independent” entity would be described as, for example, a licensed pharmacist not employed, under contract or connected otherwise to a long-term care facility’s pharmacy, pharmaceutical company or distributor.

The agency explained that it meant to rid a consultant pharmacist of any financial ties to any long-term care pharmacies or facilities that would prevent him or her from providing impartial drug regimen reviews and evaluations.

In April 2012, CMS unveiled a final rule that would not enforce such a regulation but instead invited comments on the topic. Still, the agency indicated that it would continue to examine the matter of enacting a rule to render long-term care consultant pharmacists independent.

The Role of Consultant Pharmacies in Long-Term Care

Over 20 years ago, industry experts say consultant pharmacies were formed to guarantee that long-term care patients receive the correct medications in the proper dosage at the right time.

Responding to projections of a growing aging population at the time, pharmaceutical companies developed dozens of drugs for each of the most chronic illnesses such as Alzheimer’s disease, diabetes, osteoporosis, rheumatoid arthritis and respiratory lung disorders, they say.

Overtime, such pharmacies evolved to empower 10,000 pharmacists nationwide to provide a broad range of administrative, distributive and clinical services to nearly two million mostly assisted living and skilled nursing facility patients. The most progressive pharmacies would be staffed with other medical professionals such as nurses, physicians, dietitians and laboratory staff.

Seniors, who make up the majority of long-term and short-term care patients, are the main focus of third-party consultant pharmacy practice because they are the most likely to endure drug-related hurdles such as adverse drug reactions, toxic interactions, improper use and fatal, repeated drug administration. As a result, elderly patients account for billions of dollars in drug costs.

According to the American Society of Consultant Pharmacists (ASCP), third-party consultant pharmacists tied to long-term settings provide pharmacological services; educate facility staff and administrators about medicine; serve as clinical practitioners; advocate quality care for patients and families, and; join a patient’s medical team.

Third-party, long-term care consultant pharmacists review drug regimens (DRR); evaluate drug use; develop new formularies and drug distribution systems; assess the health of facility patients; create plans of care; promote infection control; support diet and nutrition services; craft clinical policy and procedure; order and interpret laboratory tests; participate in state surveys, and; engage in clinical research.

They also handle durable medical equipment (DME); perform surgical appliance fittings; counsel patients on pain management; initiate intravenous therapy for patients; create and improve quality assurance programs; manage enteral feeding products; ensure outpatient packaging compliance; provide home diagnostic services; maintain medical/surgical supplies, and; generate computer forms and reports.

Additionally, the federal agency CMS regulates third-party consultant pharmacists to visit licensed nursing facilities every 30 days to provide drug regimen reviews for all patients served.

Long-term and short-term categories of care served by third-party consultant pharmacies include acute care hospitals; adult day care; alcohol/drug rehabilitation centers; ambulatory care; assisted living; community-based care facilities; congregate care; continuing care retirement communities (CCRC); correctional facilities; group homes; health maintenance organizations (HMOs)/preferred provider organizations (PPOs); home health agencies; hospice or post-surgical/palliative care centers; industrial plants; mental institutions; nursing homes; senior independent living, and; skilled nursing facilities.

The most common categories of care that consultant pharmacies serve nationally are assisted living facilities with between 30,000 to 40,000 such centers caring for more than one million persons, and, skilled nursing facilities.

Throughout the country, the remaining most common categories include board and care with 32,000 licensed homes for 500,000 persons; adult day care with 10,000 projected to be built and maintained by the end of the decade, and; home health care at 14,000 such agencies serving six million patients.

Additionally, the pharmacies nationwide serve hospice care with 2,500 centers serving 340,000 persons a year; CCRCs to grow from 1,000 at present to 10,000 over the next few decades; senior independent living with more than 2,500 communities, and; senior citizen centers as 12,000 of them serve between five and eight million patients annually.

Insurance Company Audits

Independent pharmacies, especially those that dispense drugs and may or may not necessarily provide consulting services, must anticipate pharmacy compliance audits and more pharmacies have been subjected to them in recent years.

Before an audit occurs, an audit and compliance vendor/contractor will mail an independent pharmacy a notice, describing plans to visit this facility to carry it out. These vendors or contractors tend to represent third-party prescription insurance companies.

Two weeks before this appointment, an assigned representative will phone a pharmacy to confirm his or her visit. An independent pharmacy may be faxed a copy of all of the prescriptions that must be inspected. The pharmacy may not receive a entire code number but sufficient information to retrieve a prescription drug file.

On the day of the audit, the pharmacy may need hired help to assist with the retrieval, replacement, document management and delivery of the necessary paperwork during the whole process.

Hired help comes in the form of a pharmacy assistant or the pharmacy’s pre-existing ancillary team. A pharmacy needs an assistant or team because an auditor’s direct questions will become more complex if data is not made available.

Consequently, an independent pharmacy must ensure that the pharmacy assistant or team comprehends the company’s entire prescription billing and recordkeeping process as it will satisfy an auditor’s quest for answers.

First, a pharmacy must be sure to make its signature logs, whether electronic or manual, policies and procedures manuals and compound formula worksheets easily accessible. Auditors will request to see its policies to judge how the pharmacy handles compounding even if it performs very little. They may also demand to view its policies on delivering drugs to facilities or patient’s homes.

Some audits can truly escalate. They may examine claims submitted two years ago and may peruse at at least 100 or more prescriptions in an afternoon. Any gaps or inconsistencies may require an adjustment unless an audited pharmacy can produce documentation as evidence of the claim. A mere undocumented refill in a pharmacy’s computer may result in thousands of dollars in adjustments.

When the audit is complete, a pharmacy will receive reports about an auditor’s revelations and adjustments. Adjustments of several thousands of dollars may appear in the audit, which translates into money that the pharmacy may have already paid that an insurer may hold back from future payments until that sum is paid in its entirety.

In fact, it may not escape an audited pharmacy that the auditors focus most of their attention on drugs with the highest potential for financial withholding. An audit may review all of the most expensive prescriptions, insulin pens and vials, brand-name inhalers and any other drug that was reimbursed for more than $500.

While this aspect of the audit is clearly imposing, a pharmacy still has legal recourse to appeal its findings. By state or federal law, an audited pharmacy has 30 days to send documentation that challenges these adjusted claims.

An audited pharmacy is urged to examine all adjustments meticulously. If a prescription lacks refill authorization, the pharmacy should consult a prescribing physician and explain the circumstances of the audit. In turn, the physician must account for the missing refill documentation on letterhead and most are willing to cooperate to assist a pharmacy in this endeavor.

Adjustments of drug supplies that last a matter of days can be appealed for partial pay. Even partial pays on costly drugs can be worthwhile. Categories of drugs that warrant calculations include insulin, drops, topicals, inhaled therapy and liquids.
Challenges To Independence

Many in the industry agree with federal agencies on the importance of third-party independent pharmacists forming their own consulting practices without dispensing medicines whether they’ve just completed their studies or have worked in their professions for a long time.

However, industry experts also acknowledge the difficulties faced by pharmacists to create their own entities with the roles they play in patient care, payment and reimbursement trends and the manner in which they deliver care.

Under the new payment and modes of delivery that include accountable care organizations (ACOs) and bundled Medicare/Medicaid payments, third-party consultant pharmacists are finding it harder to deliver cost-effective, quality patient services that would help avoid hospital admissions as required by the federal ACA law and the CMS’ Hospital Readmission Reduction Program.

Third-party independent pharmacies face the challenges of decreased reimbursements, shrinking margins and large national drug chains planning mergers and acquisitions, thus raising the potential for them to act with a conflict of interest such as making profits off distributing drugs.

However, these same pharmacies are providing new types of services such as medication therapy management and synchronization and are searching for new opportunities to grow and achieve different means of generating incomes.

Developing Independent Practices

Industry experts say that a third-party, independent consultant pharmacy is not restricted to a choice few practitioners and a specific academic degree is not required.

They say that any licensed pharmacist can open up an independent practice as long as they have a solid background in pharmacotherapy, an interest in the field of geriatrics and are grounded in an understanding in the drug and therapy needs of this age cohort.

In other words, knowing how to make recommendations to long-term care facility staff and administrators and understanding what drugs and dosages should be used for seniors is a good start for a long-term care pharmacist who wishes to grow an independent consultant practice.

Such an independent consultant pharmacist will become a Certified Geriatric Pharmacist under the National Commission for Certifying Agencies (NCCA), the accrediting body created to evaluate and regulate pharmacists, ensuring that they have the requisite knowledge in geriatric pharmacotherapy and ability to provide drug care to elderly patients.

To start their practice, experts say, independent pharmacists would have to decide how much it would cost to provide services in order to structure pricing to charge the employing long-term care facilities.

They must also consider travel time, vehicle wear, technology equipment, repair and upkeep and printing costs into their budgets. All of these costs depend on the location of the facility and the number of patients they plan to serve.

Starting out, some of an independent pharmacist’s problems include the starting expense to the employing long-term care facility. Prior to such an arrangement, experts say, long-term care facilities have not borne the costs of a pharmacist’s time because long-term care consultant facilities have always used pharmacist staff as a means of reducing costs.

To convince a prospective employer to accept his or her services, an independent consultant pharmacist must be able to prove that his or her pharmaceutical care skills command a higher price, they say.

Such demonstration tactics include pharmaeconomic reviews for the facility’s patients. Medicare pays for the care of a facility’s patients on a daily basis and any funds saved from obtaining drugs would boost the facility’s income.

This, in turns, reduces the risk of hospital readmissions and ensures that drugs are carefully monitored so that the facility can avert punitive financial fees during surveying.

Industry experts say that, before embarking on building an independent pharmacy practice, a consultant pharmacist ought to explore the opportunity. He or she must conduct market research, ask relevant questions and attempt to answer them on their own.

Specifically, a consultant pharmacist must discover how many facilities exist in their location. He or she must learn whether new nearby entities like his or hers are opening and if his or her market is expanding, experts say.

The independent pharmacist must determine if these prospective long-term care facilities are pleased with the quality of services they are receiving from these rivals and exactly where the gaps in performance are.

The consultant pharmacist must find out what he or she have to offer that is different from that of his or her competitors. He or she must know how he or she would make use of his or her present talents and relationships for this new pharmacy practice.

The pharmacist must also decide what type of investment would be needed to start his or her business, the advantages and disadvantages, the staff needed and the strategy he or she devised to land his or her first assignment.


To get started, Mark Prifogle, CEO of Grandview Pharmacy in Brownsburg, Ind., assembled multiple resources to enable consultant pharmacists to begin.

Aside from the above-mentioned recommendations for planning a launch of an independent pharmacy practice, other tools are available at the following sites:

–McKesson Corporation at and by e-mailing [email protected];

–The U.S. Centers for Disease Control and Prevention at;

–The National Consultant Pharmacists Association at;

–Managed HealthCare Associates at;

–The National Association of Boards of Pharmacy at, and;

– website, specifically for starting, buying and selling pharmacies.


Alves, Jared BS, BA; Yee, Colin MPH; Coppage, Mary BA; Lukens, Ellen MPH; Advani, Protima MA; “Long-Term Care Pharmacy: the Evolving Marketplace and Emerging Policy Issues,” Avalere Health LLC, October 2015, pp. 1-33.

Leuck, Peter, “Pharmacy Compliance Audits: What Pharmacists Can Expect,” (Last accessed: Jan. 4, 2017)

McKesson Corporation, “Becoming a Long-Term Care Pharmacy: Opportunities and Important Considerations,”, 2015, pp. 1-16.

Simonson, William PHARM.D., is Associate Professor of Pharmacy Practice, Oregon State University, and Associate Professor of Pharmacy Practice, Oregon Health Sciences University, both in Portland, “Practitioner Update: Pharmacy Practice in the Long-term Care Environment,” Journal of Managed Care Pharmacy, Vol. 3. No.2 Mar/Apr 1997, pp. 189-94.

The Lewin Group, “CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services: Long-Term Care Pharmacy Primer,” (Prepared for the U.S. Centers for Medicare and Medicaid Services), Dec. 30, 2004, pp. 1-38.

Panasonic’s HomeTeam Connects Grandparents, Grandkids With Books, Games

Though living far away, Grandma wants to connect with the little ones but they are not very engaged and communicative at their young ages.

And her grandchildren need a family member to help practicing their speaking skills, reading and writing and expanding their learning through games.

This is where Panasonic’s HomeTeam video chat software comes in, said Todd Rytting, chief technology officer of Panasonic who held a briefing and demonstration of the product and the connection between healthy aging and technology at an annual conference of the American Society of Aging.

ASA is a California-based 5,000-member, multi-disciplinary organization addressing different aspects of aging.

Panasonic HomeTeam software stores hundreds of games and books so grandparent and grandchild can play and read together.

“Grandparents [want to] connect with grandchildren,” said Andrea Schneider, public relations contact with Motorola Mobility Public Relations on behalf of Panasonic’s Health and Wellness Solutions department, which develops technology for the healthcare market. “[When you are only] 5 years old, it’s hard to get going.

“The service allows grandparents to browse through books. [Their children have their] favorite animals or characters.

“[The grandchildren and grandparents] flip through pages of books. [The] grandchildren [are] learning how to read. [They are] practicing reading books.”

Panasonic’s HomeTeam staff of executives, managers and software developers released and explained their product, an online service that uses an app for the tablet, laptop and computer to access interactive books and games with video calling.

The user can download the app from the Apple App Store or Google Play and can use Androids or OS ipads.

The program enables “tech-savvy” grandchildren to read and play and grandparents to coach or guide them from a long distance, empowering the children to learn and their grandparents to form lasting relationships with them.

“It’s about an experience,” Schneider said. “It started with Skype. [Grandparents ask their grandchildren], ‘What did you do? Something? Nothing?’ You create stories and jokes. [It] brings families in [the] spirit.”

The service is accessible for free for 30 days and then a premium subscription takes effect afterward either at $8.99 monthly or at $89.99 yearly.

“One only needs to subscribe,” she said. “You see who we try to call. [You] enter someone’s e-mail address. [You] read books and games. [There is] conference e-mailing. [You] see and hear each other talk.”

Panasonic has worked with publishers such as Houghton Mifflin Harcourt Publishing company and Disney and game developers to obtain and store 2,500-plus popular children’s books and games on the website, including Star Wars, Marvel and Pixar products.

“[In terms of books, I] recently read all favorites,” Schneider said. “[There are] animal adventures [for] different ages [such as]Curious George. You click on the book. It will bring it up. [It] brings up context.”

Books and games include math flash cards, Word Aventures for vocabulary, Curious George Gets a Medal, Curious George Goes to the Hospital, Martha Speaks: Leader of the Pack and Just Grace, Checkers, Tic-Tac-Toe, Go Fish to Word Play, Chess and Animal Math.

“Each game has a tutorial,” Schneider said. “[The tutorials] show [the child] how to play. [They have] a match. A child has to know [what games he or she wants to play such as] Tic Tac Toe.

“There is a video conference. [They] read a nighttime story. You get to experience it together. You heart the book.”

Jerry Kurtze, director of new business development and innovation of Panasonic. explained that the service helps grandparents and grandchildren find interesting subjects to discuss since children under aged 10 tend to answer questions with monosyllabic replies, cannot deepen the substance of their topics and don’t speak long enough to build ties with family members.

“[Our target market is for children aged] 3 to 10,” Kurtze said. “When they get above 10, [it is hard to connect them with their grandparents]. It’s hard to get the children at ages 11, 12, 13.”

Add to this geographical, cultural and generational differences and a child’s grasp of e-mail, Skype and text messaging within nuclear families and both parties have serious challenges to overcome, she added. HomeTeam is aimed at providing grandparents and grandchildren common ground, lasting conversations and enjoyment.

“[There is no more closeness with the] nuclear family,” Schneider said. “[There is] long distance.”

HomeTeam software presents a book selected by either the grandparent or grandchild and both start to read. When one person turns the page electronically on his or her computer screen, the page is also turned in the other’s system as well. The same applies for moves during a Chess or Checkers game.

The book or game is the centerpiece of both parties’ attention but a video chat box appears on the side so they can see and speak with each other. E-mail and invitations functions are also featured to enable family members to contact and choose one another for discussion.

“[If grandparents and grandchildren want to] play games, [you go to the home screen and click] ‘go to all,’” Schneider said. “You see games available. [There are plenty of] games that [involve] younger children and young grandparents.

“There is a camera on the side. You can hear the decrease or increase [in volume]. You can hear yourself talking. All the tablets come with microphones and cameras. This is the home screen. I [can] see what’s online.

“There is a closed network. I [can choose to only have them if I] want my family members. My loved ones accept invites. “

Kurtze said that Panasonic’s HomeTeam was the result of two years of research, collaboration with company executives, managers and software developers and outreach to the healthcare market.

“We did not know what to do,” he said. “The number one [priority] is socializing with the family. We [were] led to this discussion [and] we tested sharing Web, technology and support. We found the big thing, [which was] games, books and reading.”

The more the development team learned about the public’s wants and needs, the more they were able to form partnerships with other companies and acquire text and game material, Kurtze said.

“We get a variety [of books] like Curious George,” he said. [These were for] simple reading. [These are] base-level books.”

Schneider said the team will continue research in order to offer more titles. “One of the developers [is involved in] testing,” she said. “We do criticize [the programs to improve them] and work [with] grandparents and children.”

Panasonic’s Health and Wellness Solutions department plans to add more instructional material overtime, Kurtze added.

“We will have informational books [in the future],” he said. “[These books will] teach about animals, science or [other subjects]. There’s a new medium.

“We will learn what people want. [We will] continue to add. [Then we will] adjust [our offerings accordingly].”

Care Angel Tracks Recovering Senior At Home For Families

After five weeks in the hospital for a heart operation, she is recovering at home alone in another town and state.

So how to keep track of mother?

Officially since the spring of 2015, Wolf Shlagman, founder/CEO of Care Angel in Miami and Fort Lauderdale, Fla., entrepreneur and, for 20 years, telemedicine expert, has been offering a solution.

Care Angel is a computerized system that can record and report an aging relative’s vital signs to alert families of any change in health status before they take action.

Billed the “Virtual Caregiver,” the Smart Care “artificially intelligent voice response technology” platform can be customized to record a soothing family member’s voice for the sick relative in question to hear, to provide the relative with care by landline or cell phone using Apple Play or Google Play and to provide health data about the relative for family members.

Shlagman explained that, through company research, he learned that other organizations such as the Diabetes Foundation, offered such health-oriented customized software service.

“Seniors don’t want to burden families,” he said during a demonstration/interview with this writer at an annual conference of the American Society on Aging, a 5,000-member, multi-disciplinary organization addressing different aspects of aging, in response to a question about the program’s different facets.

“[They] won’t check in. It helps seniors [become] more independent. [You] just answer the phone. It’s all audio. [You learn about mother’s vitals and you say, ‘Good’ or ‘Oh, not good.’]

“[You can then communicate by asking your mother,] ‘What’s your blood pressure? [Do you] need anything?’”

The Care Angel program answers questions by family members about their senior relative. The answers are converted into ready-to-use dashboard notification, alerts, care insights and reports on the Care Angel Caregiver app.

If the answers show that all isn’t well or the relative is in need, Care Angel will notify the selected family-and-friend network, also known in the product’s parlance as the Care Circle, to empower them to act quickly to prevent larger problems or tragedy.

“When I set my mother up [with the Care Angel system], it gives [up] information,” he said. “Who else do you want to receive alerts? [You can set up the program to send data to] friends, sisters, brothers and neighbors.”

He explained that senior long-term care and short-term care and chronic illness management in general make up two-thirds of the $3 trillion-plus spent yearly on health care.

Federal research, some of which appears on the Care Angel website, counts at least 50 million seniors in the country, which will increase to 120 million over the next 20 years and more than 1.5 billion around the world.

Research predicts that, in coming decades, adults will live at least 20 years longer, deal with several health conditions, take several prescription drugs, suffer from injuries and fight to stay alive, fully-functioning and independent.

“One of the realizations in healthcare [is that we are spending $4 trillion[-plus in] health care [costs],” Shlagman said. “Two-thirds [of that is in] senior care.”

Meanwhile, about 70 million caregivers are providing much of the senior care, he added. Shlagman pointed to federal research finding senior care fast-becoming the greatest expenditure to every layer of society.

“[The industry of senior care forms] 20 percent of our gross national product (GDP) and [it is] growing,” he said. “ … The task of caregiving [can] take a decade of a person’s life.”

Nearly 40 percent of adults in the nation serve as caregivers for more than 20 hours to their aging relatives who have serious medical issues, taking its emotional and financial toll on them and their families and triggering the $300 billion in costs to businesses, insurers and other facets of society.

As a result, he said, families, insurers and businesses are confronting these issues, finding new means of enabling seniors to age in place and addressing the high costs for senior care.

“It really is about [balancing work with family obligations],” Shlagman said. “It is relevant [to] those issues. You [can’t] be there for [aging] mothers and fathers [as you balance] family [and] work. You don’t connect. Days and weeks [can pass with] no connection [to your aging mother or father].”

In response, he said, Care Angel, also titled Care Angel VIP Care Service, is meant to alleviate such healthcare costs by using technology to inform families of medical problems in advance, decreasing the number of unneeded and pricey hospitalization visits and repeat visits, enhancing results and being detailed about the health status of patients.

“We are growing our company [and we’ve done the] research,” Shlagman said of the company and the previous firms he ran. “We got bought out. We got sold. I asked a colleague of mine [to join me in a new venture and we put together our] collective experiences and know-how.”

Prior to owning Care Angel, Shlagman served as CEO and founder of Consult-A-Doctor from 2007 to 2013, a former telehealth company connecting patients to physicians, and to MyCity Networks, an IT company.

He added that he and his business partner were inspired by their own roles as caregivers to their aging mothers.

“I realized how I took care my mother [and] my partner took care of his mother for 10 years,” he said. “[We both] had caregiving duties and tasks. … It [caregiving] impacts so many people. It has a ripple effect into life and work.

“Among [several] things in my head, [we thought about] what was going to be [our] approach. We really came together [to study this]. We had research and sleepless nights.

“[What we offer through Care Angel] is not out there. I looked at [several programs].”

Shlagman said that the flu, a fall or the wrong medication can worsen matters for chronically ill seniors and their families.

Vital details such as skipping prescriptions, neglecting to make refills, not drinking enough water or other fluids, not eating enough or at all and being inattentive to symptoms should not be overlooked — just because, for instance, an aging mother does not wish to phone family members and burden them with her troubles, he added.

“My mother takes medications,” he said. “She’s up and down. I don’t know how she feels. Care Angel [would serve as a] virtual caregiver, checking on mother [and her] blood pressure [and] alerting me and family members when something’s wrong. [Care Angel is meant to] prevent [mother’s health status from escalating [into something] worse.”

Shlagman said that Care Angel executives and product developers researched and thought about the absence of family caregivers from the care of seniors at home and the level of expense and training required to hire home health care nurses and other staff and to purchase medical devices for use in their homes.

“Home [health care] workers [and] devices in the home are costly [to hire and purchase],” he said. “[There’s] a lot to learn and train. [There’s] a lot involved.”

He added that his team also also took into account every phase of senior care in designing the Smart Care platform.

“We saw [the] senior care continuum [and took it into consideration when developing Care Angel],” Shlagman said. “[It] shifts management [of] care [of] seniors [to this system]. [It helps the] family [keep track of mother].”

They also pondered ease and convenience in developing the platform.

“Our solution is aimed at being so simple since you need to answer the phone,” he said. “You can reach out and talk [to your aging relatives about] services.”

First, a family member using Care Angel registers with the platform and starts the app. He and she then clicks on a green circle with a “person+” icon on the page.

A Care Wizard will appear and instruct the family member to go through the sign-up process, which, Shlagman said, takes two minutes. During registration, he or she will be given the choice of recording a personalized greeting.

If the family member elects to, he or she can click on an “Care Recipient” icon and a “gear icon.” Finding a “Greetings” tab and a pencil icon, the family member can record and listen to his or her recording or hit “Re-Record” to start again.

“[A family member signs in to] Care Angel [and adds all of the information, following the instructions,” he said, demonstrating the platform at the conference. “You tell the system] who to watch [whether that is] mother [or] father and what conditions [they have]. I can record my voice.”

The calls to the aging relative from the Care Angel platform are referred to as “Care Angel VIP Care Calls,” which, Shlagman said, take less than two minutes.

The default setting allows the program to phone once on Monday, Wednesday and Friday but family members can edit the defaults to customize the system for their sick relative’s needs, he added.

Questions include “How did you sleep? How do you feel? Are you in pain? Did you take your medicine? How is your appetite? Did you drink enough water? Have you been exercising?” The system also inquires about blood pressure, blood sugar and oxygen level of the aging relative.

“[Care Angel will] call mother from the app,” Shlagman said. “ … [The] service will call [the family to let them know what is happening]. [The family] checks in on her. It [asks] her questions. [It learns if] she’s in pain [or if there is] blood.”

Family members can view data about the senior relative daily, weekly or monthly on the Care Angel VIP Care dashboard if they set it up and have access to Care Insights to learn about negative or positive health trends concerning the patient.

“[When we program the system,] we are asking [Care Angel] to take [our loved one’s] medical, blood pressure and glucose readings,” he said. “[The system] tells us what [mother’s vital signs] are. [The] reports [on mother’s vital signs] will be sent to families.”

In fact, the dashboard, which obtains its data from the Care Calls, includes information about the relative on sleep, feelings, needs, water, exercise and appetite. The Vitals section of the dashboard contains readings on blood pressure, sugar and oxygen levels if the family members set up Care Angel to retrieve it.

Through the calls and Care Alerts, the members can learn, for example, whether the relative is drinking enough water, taking his or her medicines or what their blood pressure readings were in a month.

“I [as a family member] will get alerted,” Shlagman said. “I will see the Care [Angel] insights, including blood pressure and glucose. [I learn if she is] sleeping or [how she is] feeling or, [for example, what is her] glucose [level].”

The Medications section of the dashboard exhibits whether medicines were taken, missed, skipped, ran out or were scheduled to be taken later. The Care Reports section maintains a summary of the relative’s health data in one site.

“Mother has high blood pressure,” he said. “[The Care Angel programs] are managing the blood pressure. [The Care Angel programs] are self-managed. [The program is designed to guarantee prescription drug use] adherence [and to deal with] unplanned [events].”

And the entire system can be accessed by families for free.

“Millions will use [it for] free,” Shlagman said, mentioning other software platforms Pandora and Spotify in terms of pricing and profit margins. “[There are] additional features. We want to provide as much value [as possible]. We [want to provide] additional value.”

He added that he worked with a number of senior-care organizations at the conference to forge partnerships to support and further develop Care Angel.

“[I am] working [with] partners at this conference,” he said.

“Everyone [is] in the care continuum. We may interface [with] organizations and may have contracts. [We are interested with partners who want to] help seniors and lower costs [for families]. A lot of [people] want to add value. [A] lot of customers look at what we are giving [them].”

Shlagman said that his team is dedicated to growing and enhancing Care Angel.

“Whenever you have any product, it’s a living, breathing thing,” he said. “You can get incredible [results]. [There is] constant [research and fine-tuning]. [It’s] never-ending. [It’s more] improvement. [We] take feedback.

“We want to help a million-plus families. [We are] helping families watch their loved ones. We [will] grow as quickly as it takes [to make it] grow.”

Age-Friendly Banking Instructs Seniors On Services, Guards Against Abuse, Experts Say (Part Five)

Chen said the Federal Reserve Bank there hosted two discussion events of their own. Participating seniors learned what services are being offered by their local area banks. Quarterly newsletters are released about these services and products. The center’s work is available at its website at

In like fashion, Aery said the coalition recruits ambassadors to teach seniors about financial abuse and exploitation issues and to go to Sacramento, the state’s capital, to lobby on their behalf. The ambassadors are recruited in Folsom in Sacramento County in California.

“[These seniors are visible] advocates for [all] elder adults in their community,” she said. “[They are] valuable partners [and model] citizens [in our initiative].”

One of the most critical pieces of legislation watched by the coalition is the California Homes and Jobs Act (SB 391), a popular bill designed to provide jobs, financial investment and safe and affordable apartments and single-family homes for state residents in need, including families, seniors, veterans, the disabled and the homeless.

As of February 2014, with 31 co-authors, 600-plus sponsoring organizations and 400-plus individual sponsors, the bill lacks three votes in the state legislature to achieve passage into law.

Rangel, Bank of the West’s senior executive, said her bank provides a financial services roundtable of BITS, a non-acronym of an organization also known as the Financial Services Roundtable’s Technology Task Force, which represents an association of the nation’s 100 top financial services with interests in technology.

Bank officers provide services in financial exploitation, at-risk adult training curriculum and education, fraud detection, identity theft and secure retirement and a working group on these issues.

“[We look at and address] challenges and impediments,” she said of her bank. “[We provide] group training for advocates and education for seniors. BITS [serves by providing the] at-risk adult training curriculum.”

Rangel said that the bank contacts other banks and tries to avoid embarrassment for its senior customers with respect to financial abuse and exploitation. She said bank officers check credit reports to protect older customers against identity theft.

“[We make sure our senior customers] stay active and engaged with others,” she said. “[We ensure that they] establish [a] budget and keep money management.

“Isolation is a great danger. [It is important that our senior customers] protect [their personal and financial] identity. [We caution them not to] give away [their] Social Security numbers. [We try to] take away [the] stigma [of their victimhood for abuse and exploitation].”

Rangel said that Bank of the West sponsors “Be Aware” workshops. The bank started the program in 2007 to comply with California laws requiring banks to create and host customer education workshops.

“[We] partnered with nonprofits,” she said. “[We] let the [bank] branches [customize their educational programs]. [We brought in community] resources, law enforcement agencies and [the] FBI [in to] talk about scams. [We had participants] share [their] experiences.”

Rangel added that the bank took part in a governmental program, especially with the different counties and other states to enable industrial shredders to dispose of documents containing sensitive data about senior customers.

As an example, she said, one of the bank branches in Omaha, Nebraska sponsored an event program titled “Be Aware” Seniors. The program was started and run by a legal aid society in Nebraska, she said. The Attorney General in Nebraska provided a free shredding service.

Rangel said the bank “[carried out much of the] heavy lifting” to inform seniors about financial abuse and exploitation on their website. The nonprofit Elder Financial Protection Network’s (EFPN) work can be viewed at and

She said the development of the website was “labor intensive [and took] a lot of time to manage in 2009”. The intent, Rangel said, was to reach more people about financial abuse and exploitation.

“[Our bank was responsible for] education and outreach [with a] broad dissemination [of content to our] target audience,” Rangel said. “[In our materials, we] defined financial elder abuse [with an] actionable message [from] trusted sources. [We formed] partnerships [with a variety of public and private sponsors].”

Event participants were advised not to let caregivers isolate seniors and urged them to make surprise visits of their homes.

The bank participated in and supported the San Francisco District Attorney’s campaign, she added. The campaign was a citywide multilingual business advertisement effort on elder financial abuse. She said the bank made sure that its officers generated “linguistically and culturally appropriate community outreach and press events [and materials].”

Rangel said the challenges of the bank’s age-friendly banking initiatives are “reporting out of their benefits, licensing of financial professionals serving elders, meeting the need for additional education and lobbying support for a national reporting statute.”

She explained that it is the duty of the executor of a will and the power of attorney to exercise the authority to authorize a protective hold on a customer’s finances and property and to grant permission based on age-based fraud monitoring.

“[We need to ask basic questions like:] are we violating other laws by monetary fraud?” Rangel said. “[We need to address the] hold harmless [clauses and instances of] suspected fraud.”

She explained that the bank approaches the financial institution’s trusted advisor on behalf of its customers. Bank officers take into consideration the turnaround time for reporting and exercising authority.

The bank performs internal training on SARS, also known as “suspicious activity reports” and trains families. Its officers check for fraud and the speed with which it is committed. During banking events, the officers field questions in the audience about the training and fraud monitoring programs. Many banks participate in the Elder Financial Protection Network, a “turnkey solution” meant to address the financial abuse and exploitation questions that has “received a great deal of support,” she said.

“[Seniors are at a] vulnerable stage [in their lives] and [have] given so much to society,” Rangel said. “[We believe it is worth the effort to] galvanize people to care about this.”

Read This Story From The Beginning:

Part One

Part Two

Part Three

Part Four

This article was originally published March 10, 2014 on the website of, one of seven websites that comprise The Pharm Psych Network, a medical communications and education company.

Age-Friendly Banking Instructs Seniors On Services, Guards Against Abuse, Experts Say (Part Four)

“[This meant that there were] a lot of people [without affordable housing in California. There was] only one of me, my boss and support staff [performing this work]. We wanted to produce something of value.”

Firstly, Aery said, the coalition performed assessments of units and properties in rural communities. Coalition staff visited the member organizations in their offices. They examined the current services of their organizations, resident characteristics and site capacity.

Secondly, coalition personnel examined the implementation of the coalition’s recommendations and directives through resident surveys, educator workshops about financial empowerment and roundtable discussions, she said.

The surveys consisted of 11 questions, which were multiple choice, and were meant to be confidential. Aery said that the objective was to discover what seniors were dealing with in terms of banks and financial exploitation.

She explained that senior respondents were asked about checking accounts, banking and check cashing. Coalition staff found it interesting to tabulate the number and type of questions they skipped on the surveys.

“[We examined] implementation [at our] roundtable discussions,” Aery said. “We wanted to show real people are being affected. [We wanted to] do something other than surveys.

“[So we carried out] raffles for surveys. [We had] appetizers [and drinks for] two-hour long discussion events.” The events occurred at the Reserve Bank in Napa, California.

At the event, she said 15 to 25 older adults related the incidences of quality services, abuse, neglect and exploitation they experienced and the time of the events. There were three- to five-person discussion groups to allow them to share stories of banking experiences.

She added that coalition staff discussed implementation of the umbrella group’s recommendations of housing and financial services at the financial education workshops. Coalition personnel have used these discussions and data to implement solutions to the problems raised by seniors attending the event.

The seniors at the event, Aery said, “strengthened the well-being of their peers [through open dialogue].”

“[We talked about] examples,” Aery said. “[We presented scenarios of seniors who] won a fake lottery or [who participated in] a fake banking event. [Seniors explained] what they [would] like to [have] happened and [what actually] happened. Each group talked to everyone [after their own discussion sessions]. People were excited.”

Elaine A. Chen, training coordinator of the Center of Excellence on Elder Abuse and Neglect at the University of California at Irvine School of Medicine’s Division of Geriatric Medicine and Gerontology in Orange County, Calif., said the center is performing similar age-friendly banking activity. The center serves as the local clearinghouse for the federal National Center on Elder Abuse with funding from the federal Administration on Aging (AoA).

Continued: Part Five

This article was originally published March 10, 2014 on the website of, one of seven websites that comprise The Pharm Psych Network, a medical communications and education company.

Age-Friendly Banking Instructs Seniors On Services, Guards Against Abuse, Experts Say (Part Three)

“[We make] recommendations [to enable banks to] create and customize financial products, [including] low-cost, low-fee accounts,” Zdenck said. “[This] requires financial institution staff to identify fraud and abuse. [It all supports] age-friendly banking.

“[Under the GO Direct program sponsored by the Federal Reserve Bank and the U.S Department of the Treasury,] all benefit payments [are scheduled] to go electronic. Direct deposit [is] better [for seniors] than debit cards with hidden fees. Yearly benefit check-ups [are offered] for older adults [to ensure that they are being served properly by government agencies]. [And we help banks work to] expand housing and financial options. [We examine and improve upon] CDFJs [County Department of Job and Family Services] and reverse mortgage.”

The next steps are to generate age-friendly banking papers, Zdenck said. NNS must provide introductory policies, campaigns and age-friendly banking standards to further assist banks in helping seniors, he said.

“[We need to look at the] recession in terms [of] elder abuse,” he said. “It’s so underreported. [There is] an uptake in outreach efforts. [For example, the] Hispanic community [is in great need of such initiatives to examine and prevent elder abuse].

“It may be [a series of life] circumstances [that are involved]. [The] climate [of the caregivers may not be conducive to ending elder abuse]. Elders [should] feel comfortable [enough to conduct financial activity without the fear of abuse]. They [should] know what steps to take and how to report crime. We are realistic partners [with banks] when it comes to assessing and acting on the life circumstances of seniors].”

Stacey Easterling, Program Officer of the Atlantic Philanthropies, the National Council on Aging (NCOA), a nonprofit senior services organization, and Better Directions, a program by the National Federation of Community Development Credit Unions to help low-to-moderate income seniors become economically secure, formed a team to develop and offer earned income credit to low-to-moderate income taxpayers around the country through the Internal Revenue Services (IRS). Benefits checkup for individuals, especially seniors, is only available in at least 20 states, he said.

“We don’t expect [a] doubling [of] banks, [especially the most age-friendly ones],” Zdenck said. “Banks are [expected to learn about], understand [and urge their aging customers to use] benefit screening. Elder individuals are not the only ones who don’t [know about this service].”

NCOA developed benefit calculators of government social assistance programs online at to enable individuals to determine which forms of aid they qualify for in their states of residence.

Rebecca Rangel, senior vice president of community affairs of Bank of the West in San Francisco, which has branches in 19 states in the Midwest, West Coast, North Central and Southwest regions of the country, said that benefits screening impacts the tax season because of seniors’ financial and government benefits habits.

“IRS has a form [known as the] 888 refund,” Rangel said of the IRS application sheet used to direct taxpayers’ refunds to their bank accounts or to purchase savings bonds.

“[If seniors] don’t see [the] money, [then they] don’t spend. [The idea is to] increase bank networking. Younger people are decreasing bank networking. [They are banking more and more by] telephone [and on the] Internet. [These are critical issues in] branch banking. [We need to make our banks] more accessible.”

To learn more about senior’s banking practices and experiences, Sonia Aery, director of the Asset Building programs of the California Coalition for Rural Housing in Sacramento, Calif., said her organization performed their own research. The coalition’s work can be viewed at its website at

One of the discoveries made through research, Aery said, is that California has one of the oldest housing industries in the country as well as some of the most affordable homes, many of which are owned or occupied by seniors. The coalition has 15 grantees receiving funding and technical assistance to support community empowerment and eco-activity.

She added that there are three phases of coalition work: the invitation and engagement of member organizations under the umbrella group, assessment of the state of housing and socioeconomic status of communities and the work of the organizations and the implementation of their solutions to issues and problems.

To perform the assessment aspect of the coalition’s work, Aery said that research was conducted on its member organizations.

“[We] sent surveys to [community housing] developer members [of our coalition],” she said. “[We asked what was the] number of [housing] properties [in the state and] where [were they located. How many tenant organizations [were there]? [We learned by] RSVP [that there were] 3,400 [affordable senior housing] units [and] 64 properties statewide.”

Continued: Part Four

This article was originally published March 10, 2014 on the website of, one of seven websites that comprise The Pharm Psych Network, a medical communications and education company.

Age-Friendly Banking Instructs Seniors On Services, Guards Against Abuse, Experts Say (Part Two)

With the struggling economy, bank savings among the nation’s population, including seniors, are decreasing and the use of defined benefits is rising. Additionally, Social Security accounts for 30 percent of the average older adult’s income and this figure is growing, he added.

Zdenck said federal research also found that 19 percent of seniors are unbanked; they didn’t have a bank account or participate in any banking services at all. The reason, he said, is that many seniors feared predatory lending, financial fraud, abuse and exploitation.

“[It] surprised me,” he said. The American Association of Patients and Providers (AAPP), a Seattle, Wash.-based organization aimed at promoting more efficient and cost-effective delivery of healthcare services, and the Center for Financial Services Innovation (CFSI), an organization targeting “unbanked” and “underbanked” consumers, such as seniors and low-to-moderate income families and communities, released the figures.

To carry out the research project, a survey of interviews of 14 of the largest banks in the country was conducted. The investigative effort consisted of financial practices research data and expert interviews and relied on the experience of banking practitioners.

“[Researchers learned that] financial institutions had no data on older adult customers,” Zdenck said. “No single bank [the researchers interviewed] developed an array of comprehensive products and services armed at seniors. Services [didn’t] meet the needs of older adults.”

As a consequence, he said government agencies such as the Consumer Financial Protection Bureau (CFPB), the Federal Trade Commission (FTC), the Federal Reserve System (FRS), the Office of the Comptroller of the Currency, Federal Deposit Insurance Corporation (FDIC)’s Consumer Response Center and state banking authorities, the National Credit Union Administration (NCUA), the Small Business Administration (SBA) and the U.S. Department of Commerce worked with the banking, housing, community development and geriatric medicine sectors to address this gaping need.

“[We need to] improve regulations, data collection and law enforcement at the state and federal boards,” Zdenck said. “[We] work with federal regulators to have [aging in place directives] as explicit [as the] CRA [Credit Reinvestment Act] investment and [bank] service test [to motivate banks to invest in low-to-moderate income and disadvantaged communities].

“Our principles [are to] protect older adults from fraud and abuse. [We are constantly] adapting and learning [how to achieve this better]. [We] train bank officials on detecting fraud and abuse. [We get them to] customize financial products and services for older adults. [We get them to] offer transparent, low-cost, low-fee accounts. [We ask them to] expand affordable financial management.”

Zdenck said NNS and other federal agencies must help banks to engage seniors in investigating the government benefits that may support them.

“[We help their customers to] access critical income supports and offer education to older adults,” he said, stating that NNS’ Housing Counseling Network and National Training Academy provides seniors with financial and housing consumer education.

“Financial institutions should have benefit screens. [For example, seniors are] not applying to food stamp programs or SNAP [the federal government’s Supplemental Nutrition Assistance Program] because they don’t know about them.”

Zdenck said that one of the issues raised by seniors about conducting business with banks is their physical accessibility. He said that LEED represents voluntary standards for building designs and the banking, architectural and civil engineering markets responded to the government’s age-friendly banking endeavors with implementing them to accommodate senior customers. As a result of government and business partnerships, most bank branches are now LEED-certified.

“[The development and opening of branch banks is] modeled after LEED building principles,” Zdenck said, explaining that LEED, also known as the Leadership in Energy and Environmental Design program by the U.S. Green Building Council (USGBC) to regulate environmentally correct building and construction.

“[We want to] improve access to bank locations and services [and build and open more] bank branches and online development. [To further physically accommodate seniors, we want to] facilitate aging in the community [with such services as] home repairs and modifications.”

He said that NNS assists banks in providing products and services, offering income supports and benefits and housing counseling to seniors. This has reduced the number of unbanked seniors.

Continued: Part Three

This article was originally published March 10, 2014 on the website of, one of seven websites that comprise The Pharm Psych Network, a medical communications and education company.