“Losing as little as 5 – 10% of your body fat can go a long way in improving the health of the body and in helping the organs perform their functions efficiently”

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The St George’s Health Centre will reopen on Monday, 27 November 2023

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(2) It has also been reported that South Asians are more susceptible to developing T2DM as compared to the Western population. (1)

Multi-Comorbidity Burden with Type 2 Diabetes Mellitus (T2DM)

The comorbidities and complications add to the burden of diabetes. Reportedly, 75% of patients have at least one additional comorbidity at the time of T2DM diagnosis, and 44% have at least two comorbidities. (3) Among Indian T2DM patients, high blood pressure (28.5%) is reported as a major comorbidity, followed by rheumatism (24.4%), retinopathy (21.8%), and cardiovascular diseases (19.5%). (4)

Therapeutic Approach in Type 2 Diabetes (T2DM): Overview

The latest American Diabetes Association 2023 guidelines recommend that a patient-centered approach should guide the choice of therapy. (5) Patient-related factors such as age, presence of comorbidities and cardiovascular (CV) risk, and treatment-related factors such as individualised glycemic targets, avoidance of hypoglycemia and weight gain, cardiorenal protection, minimal side effects of the medications, and treatment costs are important factors that must be considered when managing T2DM. (6)

Combination of Dipeptidyl Peptidase IV Inhibitors (DPP-4i) and Sodium-glucose Cotransporter-2 (SGLT2) Inhibitors (SGLT2i): Opinion from the Indian Experts

Compared to monotherapy, combination therapy improves treatment adherence and tackles several pathophysiologic defects in T2DM, enabling faster blood glucose control. Evidence from several clinical trials suggests that the SGLT2i+DPP4i combination is efficient and safe in controlling glycemic parameters in T2DM patients. (7) SGLT2 inhibitors have a unique insulin-independent mechanism of action and clinically proven weight lowering, blood pressure lowering, and cardiorenal-benefits. DPP4 inhibitors are weight-neutral; neither of these drug classes induce hypoglycemia. (8)

An expert opinion published on the optimal clinical approach to the combination use of SGLT2i + DPP4i in Indian diabetes settings suggests using SGLT2i+DPP4i fixed-dose combination in uncontrolled type 2 diabetes on Metformin with HbA1c >8.5% and among treatment-naive T2DM patients with HbA1c>8% in whom Metformin may be contraindicated or not tolerated. The SGLT2i+DPP4i combination may assist weight loss while providing benefits in T2DM patients with a higher predisposition to CV events and kidney disease. (7)

Linagliptin and Dapagliflozin: Applicability Across the Continuum of T2DM Care

Linagliptin is a DPP-4 inhibitor clinically useful for improving glycemic control in adults with T2DM. It offers a lower risk of hypoglycemia than other antidiabetic therapies and is weight-neutral. Importantly, it does not require dose modifications in a broad range of patient populations. It has a reassuring safety profile with robust evidence in T2DM, especially in cases of cardiac and renal comorbidities. (6)

Dapagliflozin is a highly selective SGLT2i that induces glucosuria by inhibiting glucose reabsorption in the kidney's proximal tubule. (9) In addition to potent blood glucose lowering effects, it has clinically established benefits beyond glycemic control, including lowering the rates of serious cardiovascular events, CV death, and hospitalisation for heart failure (HF) among T2DM with high CV risk. It also reduces the progression of CKD. (10)

Linagliptin & Dapagliflozin: Robust Glycemic Benefits

Linagliptin improves glycemic control in a varied T2DM population, including Asians, as established in several clinical trials and real-world evidence. (11) Treatment with Linagliptin reduces HbA1c level by 0.94%, fasting blood glucose (FBG) by 31.81 mg/dL (12), and postprandial glucose (PPG) by 33.5 mg/dl in T2DM patients. (13) Additionally, linagliptin treatment reduces the need for other glucose-lowering therapies, including insulin addition and up-titration. (11)

Dapagliflozin reduces glycemic fluctuations without increasing hypoglycemia episodes in patients newly diagnosed with T2DM. Treatment with dapagliflozin among T2DM patients has shown a reduction in HbA1c by 1.1%, FBG by 31.6 mg/dL, and PPG by 54.9 mg/dl. (9)

Linagliptin & Dapagliflozin: Reaping CV-CKD Benefits in Type 2 Diabetes

Linagliptin: Linagliptin reduces CV risk by 6.36% (P= 0.017), lowers triglyceride by 31.70 mg/dL [P=0.009] (12) and LDL-C by 41.9 mg/dL [P<0.05] (14). Treatment with Linagliptin also reduces albuminuria by 32% [P<0.05], indicating reno-protective benefits (15)

Dapagliflozin: Treatment with Dapagliflozin reduces CV death by 45%, hospitalization for HF by 36%, and all-cause mortality by 41% among T2DM with Heart Failure with reduced Ejection Fraction (HFrEF). (10) It also reduces the risk of ventricular arrhythmia, resuscitated cardiac arrest, or sudden death by 21%, (16) atrial fibrillations and atrial flutter events by 19% [ P=0.009] (17).

Dapagliflozin reduces albuminuria by 33.2% (95% CI −45.4, −18.2) in T2DM with hypertension (18). The subanalysis of the DECLARE-TIMI 58 trial has shown positive impact of Dapagliflozin on renal outcomes with no evidence of modification of treatment effect (P=0.28 and P=0.52). (19)

Linagliptin & Dapagliflozin: Effectiveness in T2DM Across Liver & Kidney Impairment & CVD :

Liver Safety:

Linagliptin: Linagliptin can be safely used in T2DM patients with mild to moderate liver dysfunction as opined by 87% Indian HCPs in a recent position paper on Linagliptin in T2DM management. (6) A pooled analysis of 17 randomized trials (n=7009, 39% Asians) showed that the adjusted mean change in HbA1c from baseline in those with hepatic disorders (hepatic steatosis, hepatitis C) was −0.75% ± 0.05 with linagliptin and − 0.20% ± 0.08 with placebo (P<0.0001) over 24 weeks. These suggest that linagliptin is effective and safe in people with T2DM and liver disease. (20)

Dapagliflozin: Dapagliflozin is well tolerated and associated with improvements in body composition and visceral fat, as well as improvements in liver parameters (serum concentrations of aspartate aminotransferase and alanine aminotransferase) and metabolic variables such as FPG, insulin, HbA1c, HDL-C, LDL-C, and triglycerides in patients with NASH associated with T2DM. (21)

Kidney Safety:

Linagliptin: Linagliptin is the only gliptin to have renal safety evidence, with demonstrated effectiveness across the spectrum of CKD in T2DM. (6) The KDIGO (Kidney Disease: Improving Global Outcomes) 2022 guidelines noted the favourable effects of linagliptin and recommended its use as no dose modifications are required. (22)

Dapagliflozin: Dapagliflozin has renal protection function and controls the progression of diabetic nephropathy by enhancing glomerular and renal tubular function and decreasing the release of TNF- and IL-6 inflammatory factors. (23) The KDIGO 2022 guideline recommended initiation of an SGLT2i for patients with T2DM and CKD who have eGFR ≥20 mL/min/1.73 m2 (a change from ≥30 mL/min/1.73 m2 in the 2020 guideline), and the ADA has also updated this threshold to ≥20 mL/min/1.73 m2 in its Standards of Care (from ≥25 mL/min/1.73 m2 in the initial issue of the 2022 Standards of Care). (22)

CV Safety- Established in Asian T2DM Patients

Linagliptin: A subgroup analysis of the CARMELINA trial (N=6979, 8.0% Asian) assessed the CV safety of linagliptin among Asian T2DM. During a median follow-up of 2.2 years, 3-point MACE (first occurrence of CV death, non-fatal MI, or nonfatal stroke) occurred in 29/272 (10.7%) and 33/283 (11.7%) of linagliptin and placebo groups, respectively (HR]0.90 P=0.3349). This suggests the CV safety of linagliptin among Asian T2DM patients. (24)

Another subgroup analyses of the CAROLINA trial showed that linagliptin showed fewer 3P-MACE (first occurrence of CV death, non-fatal MI, or non-fatal stroke events) during 6.2 years of median follow-up (9.5% linagliptin vs 11.1% glimepiride, HR 0.85, There were no significant differences between groups for other outcomes, including CV death (HR 0.73), non-CV mortality (HR 0.76) and hospitalization for heart failure (HR 0.89). Hypoglycemia adverse events occurred in 13.1% of linagliptin patients versus 42.1% of glimepiride patients (HR 0.25; P<0.0001) despite similar glycemic control. Body weight was slightly lower with linagliptin relative to glimepiride. (25)

Dapagliflozin: Dapagliflozin is well tolerated and safe in a wide spectrum of T2DM including patients with poorly controlled diabetes, the elderly, heart failure (NYHA class II or higher), or patients with CV risk factors. It decreases body weight and SBP (systolic blood pressure) in patients with poorly managed hypertension and pre-existing CVD without affecting CV safety. (26)

Clinical Takeaways

• Diabetes is growing alarmingly, and the increasing comorbidities add to the disease burden. Glucose-lowering medications with long-term durability, as well as CV, hepatic, and renal safety, are relevant and important for streamlining T2DM management.
• Linagliptin has a reassuring safety profile with robust evidence across the T2DM continuum.
• Linagliptin has been proven efficacious in the Asian T2DM population, with demonstrated cardiovascular (CV) and renal safety, improvement in the metabolic profile, and enhanced adherence due to once-a-day dosing without the need for dose modifications.
• Dapagliflozin is effective in reducing the risk of hospitalisation for HF, CV deaths, and renal disease progression.
• Dapagliflozin is well-tolerated and safe across T2DM patient population groups, including poorly controlled diabetes with high CV risk and CKD.

The combination treatment of linagliptin and dapagliflozin may be a reasonable choice as a potential ‘evergreen duo’ for managing a wide spectrum of T2DM. This is due to their complementary actions, robust glycemic control, and the associated benefits of metabolic improvement, weight and blood pressure reduction. Moreover, this combination offers cardiovascular and renal safety and can be administered once daily without the need for dose modifications, benefiting a broad range of T2DM patients.

References:

1. Yusufi FNK, Ahmed A, Ahmad J, Alexiou A, Ashraf GM, Yusufi ANK. Impact of Type 2 Diabetes Mellitus with a Focus on Asian Indians Living in India and Abroad: A Systematic Review. Endocr Metab Immune Disord Drug Targets. 2023;23(5):609-616. doi: 10.2174/1871530322666220827161236.

2. Anjana RM, Unnikrishnan R, Deepa M, Pradeepa R, Tandon N, Das AK, Joshi S, Bajaj S, Jabbar PK, Das HK, Kumar A, Dhandhania VK, Bhansali A, Rao PV, Desai A, Kalra S, Gupta A, Lakshmy R, Madhu SV, Elangovan N, Chowdhury S, Venkatesan U, Subashini R, Kaur T, Dhaliwal RS, Mohan V; ICMR-INDIAB Collaborative Study Group. Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17). Lancet Diabetes Endocrinol. 2023 Jul;11(7):474-489. doi: 10.1016/S2213-8587(23)00119-5. Epub 2023 Jun 7.

3. Nowakowska, M., Zghebi, S.S., Ashcroft, D.M. et al. The comorbidity burden of type 2 diabetes mellitus: patterns, clusters, and predictions from a large English primary care cohort. BMC Med 17, 145 (2019). https://doi.org/10.1186/s12916-019-1373-y

4. Balasaheb Bansode, Jang Bahadur Prasad. Burden of comorbidities among diabetic patients in Latur, India, Clinical Epidemiology and Global Health, 2022. https://doi.org/10.1016/j.cegh.2021.100957.

5. American Diabetes Association; Standards of Care in Diabetes—2023 Abridged for Primary Care Providers. Clin Diabetes 2 January 2023; 41 (1): 4–31. https://doi.org/10.2337/cd23-as01

6. Mithal A, Ramachandran A, Bhattacharyya A, Chadha M, Dharmalingam M, Majumder A, Sanyal D. Simplifying Type 2 DM Care with Linagliptin: A Position Paper. J Assoc Physicians India. 2023 Aug;71(8):11-12. doi: 10.59556/japi.71.0324.

7. Chadha M, Das AK, Deb P, Gangopadhyay KK, Joshi S, Kesavadev J, Kovil R, Kumar S, Misra A, Mohan V. Expert Opinion: Optimum Clinical Approach to Combination-Use of SGLT2i + DPP4i in the Indian Diabetes Setting. Diabetes Ther. 2022 May;13(5):1097-1114. doi: 10.1007/s13300-022-01219-x. Epub 2022 Mar 25.

8. Scheen AJ. DPP-4 inhibitor plus SGLT-2 inhibitor as combination therapy for type 2 diabetes: from rationale to clinical aspects. Expert Opin Drug Metab Toxicol. 2016 Dec;12(12):1407-1417. doi: 10.1080/17425255.2016.1215427. Epub 2016 Jul 29.

9. Ji L, Ma J, Li H, Mansfield TA, T'joen CL, Iqbal N, Ptaszynska A, List JF. Dapagliflozin as monotherapy in drug-naive Asian patients with type 2 diabetes mellitus: a randomized, blinded, prospective phase III study. Clin Ther. 2014 Jan 1;36(1):84-100.e9. doi: 10.1016/j.clinthera.2013.11.002. Epub 2013 Dec 28.

10. Verma S, McMurray JJV. The Serendipitous Story of SGLT2 Inhibitors in Heart Failure. Circulation. 2019 May 28;139(22):2537-2541. doi: 10.1161/CIRCULATIONAHA.119.040514. Epub 2019 Mar 18.

11. Vlado Perkovic, Robert Toto, Mark E. Cooper, Johannes F.E. Mann, Julio Rosenstock, Darren K. McGuire, Steven E. Kahn, Nikolaus Marx, John H. Alexander, Bernard Zinman, Egon Pfarr, Sven Schnaidt, Thomas Meinicke, Maximillian von Eynatten, Jyothis T. George, Odd Erik Johansen, Christoph Wanner; on behalf of the CARMELINA investigators, Effects of Linagliptin on Cardiovascular and Kidney Outcomes in People With Normal and Reduced Kidney Function: Secondary Analysis of the CARMELINA Randomized Trial. Diabetes Care 1 August 2020; 43 (8): 1803–1812. https://doi.org/10.2337/dc20-0279

12. Poonchuay N, Wattana K, Uitrakul S. Efficacy of linagliptin on cardiovascular risk and cardiometabolic parameters in Thai patients with type 2 diabetes mellitus: A real-world observational study. Diabetes Metab Syndr. 2022 May;16(5):102498. doi: 10.1016/j.dsx.2022.102498. Epub 2022 May 13.

13. McGill JB. Linagliptin for type 2 diabetes mellitus: a review of the pivotal clinical trials. Ther Adv Endocrinol Metab. 2012;3(4):113-124. doi:10.1177/2042018812449406

14. Naoto Kamatani et al, Comparison between the clinical efficacy of linagliptin and sitagliptin, Journal of Diabetes & Endocrinology 2013;4(4): 51-54

15. Groop PH, Cooper ME, Perkovic V, Emser A, Woerle HJ, von Eynatten M. Linagliptin lowers albuminuria on top of recommended standard treatment in patients with type 2 diabetes and renal dysfunction. Diabetes Care. 2013 Nov;36(11):3460-8. doi: 10.2337/dc13-0323. Epub 2013 Sep 11.

16. Curtain JP, Docherty KF, Jhund PS, et al. Effect of dapagliflozin on ventricular arrhythmias, resuscitated cardiac arrest, or sudden death in DAPA-HF. Eur Heart J. 2021;42(36):3727-3738. doi:10.1093/eurheartj/ehab560

17. Zelniker TA, Bonaca MP, Furtado RHM, Mosenzon O, Kuder JF, Murphy SA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Budaj A, Kiss RG, Padilla F, Gause-Nilsson I, Langkilde AM, Raz I, Sabatine MS, Wiviott SD. Effect of Dapagliflozin on Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus: Insights From the DECLARE-TIMI 58 Trial. Circulation. 2020 Apr 14;141(15):1227-1234. doi: 10.1161/CIRCULATIONAHA.119.044183. Epub 2020 Jan 27.

18. Heerspink HJ, Johnsson E, Gause-Nilsson I, Cain VA, Sjöström CD. Dapagliflozin reduces albuminuria in patients with diabetes and hypertension receiving renin-angiotensin blockers. Diabetes Obes Metab. 2016 Jun;18(6):590-7. doi: 10.1111/dom.12654.

19. Furtado RHM, Raz I, Goodrich EL, Murphy SA, Bhatt DL, Leiter LA, McGuire DK, Wilding JPH, Aylward P, Dalby AJ, Dellborg M, Dimulescu D, Nicolau JC, Oude Ophuis AJM, Cahn A, Mosenzon O, Gause-Nilsson I, Langkilde AM, Sabatine MS, Wiviott SD. Efficacy and Safety of Dapagliflozin in Type 2 Diabetes According to Baseline Blood Pressure: Observations From DECLARE-TIMI 58 Trial. Circulation. 2022 May 24;145(21):1581-1591. doi: 10.1161/CIRCULATIONAHA.121.058103. Epub 2022 May 5.

20. Inagaki N, Sheu WH, Owens DR, Crowe S, Bhandari A, Gong Y, Patel S. Efficacy and safety of linagliptin in type 2 diabetes patients with self-reported hepatic disorders: A retrospective pooled analysis of 17 randomized, double-blind, placebo-controlled clinical trials. J Diabetes Complications. 2016 Nov-Dec;30(8):1622-1630. doi: 10.1016/j.jdiacomp.2016.07.002. Epub 2016 Jul 15.

21. Tobita H, Sato S, Miyake T, Ishihara S, Kinoshita Y. Effects of Dapagliflozin on Body Composition and Liver Tests in Patients with Nonalcoholic Steatohepatitis Associated with Type 2 Diabetes Mellitus: A Prospective, Open-label, Uncontrolled Study. Curr Ther Res Clin Exp. 2017;87:13-19. Published 2017 Jul 8. doi:10.1016/j.curtheres.2017.07.002

22. de Boer IH, Khunti K, Sadusky T, et al. Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care. 2022;45(12):3075-3090. doi:10.2337/dci22-0027

23. Huang, Y., Lu, W. & Lu, H. The clinical efficacy and safety of dapagliflozin in patients with diabetic nephropathy. Diabetol Metab Syndr 14, 47. 2022. https://doi.org/10.1186/s13098-022-00815-y

24. Inagaki N, Yang W, Watada H, et al. Linagliptin and cardiorenal outcomes in Asians with type 2 diabetes mellitus and established cardiovascular and/or kidney disease: subgroup analysis of the randomized CARMELINA® trial. Diabetol Int. 2019;11(2):129-141. Published 2019 Oct 22. doi:10.1007/s13340-019-00412-x

25. Kadowaki T, Wang G, Rosenstock J, Yabe D, Peng Y, Kanasaki K, Mu Y, Mattheus M, Keller A, Okamura T, Johansen OE, Marx N. Effect of linagliptin, a dipeptidyl peptidase-4 inhibitor, compared with the sulfonylurea glimepiride on cardiovascular outcomes in Asians with type 2 diabetes: subgroup analysis of the randomized CAROLINA® trial. Diabetol Int. 2020 Jun 27;12(1):87-100. doi: 10.1007/s13340-020-00447-5.

26. Saleem F. Dapagliflozin: Cardiovascular Safety and Benefits in Type 2 Diabetes Mellitus. Cureus. 2017;9(10):e1751. Published 2017 Oct 5. doi:10.7759/cureus.175

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Assisted living centers have become an appealing retirement option for hundreds of thousands of boomers who can no longer live independently, promising a cheerful alternative to the institutional feel of a nursing home.

But their cost is so crushingly high that most Americans can’t afford them.

What to Know About Assisted Living

The facilities can look like luxury apartments or modest group homes and can vary in pricing structures. Here’s a guide.

Read More

These highly profitable facilities often charge $5,000 a month or more and then layer on fees at every step. Residents’ bills and price lists from a dozen facilities offer a glimpse of the charges: $12 for a blood pressure check; $50 per injection (more for insulin); $93 a month to order medications from a pharmacy not used by the facility; $315 a month for daily help with an inhaler.

The facilities charge extra to help residents get to the shower, bathroom, or dining room; to deliver meals to their rooms; to have staff check-ins for daily “reassurance” or simply to remind residents when it’s time to eat or take their medication. Some even charge for routine billing of a resident’s insurance for care.

“They say, ‘Your mother forgot one time to take her medications, and so now you’ve got to add this on, and we’re billing you for it,’” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, a nonprofit.

About 850,000 older Americans reside in assisted living facilities, which have become one of the most lucrative branches of the long-term care industry that caters to people 65 and older. Investors, regional companies, and international real estate trusts have jumped in: Half of operators in the business of assisted living earn returns of 20% or more than it costs to run the sites, an industry survey shows. That is far higher than the money made in most other health sectors.

Rents are often rivaled or exceeded by charges for services, which are either packaged in a bundle or levied à la carte. Overall prices have been rising faster than inflation, and rent increases since the start of last year have been higher than at any previous time since at least 2007, according to the National Investment Center for Seniors Housing & Care, which provides data and other information to companies.

There are now 31,000 assisted living facilities nationwide — twice the number of skilled nursing homes. Four of every five facilities are run as for-profits. Members of racial or ethnic minority groups account for only a tenth of residents, even though they make up a quarter of the population of people 65 or older in the United States.

A public opinion survey conducted by KFF found that 83% of adults said it would be impossible or very difficult to pay $60,000 a year for an assisted living facility. Almost half of those surveyed who either lived in a long-term care residence or had a loved one who did encountered unexpected add-on fees for things they assumed were included in the price.

Assisted living is part of a broader affordability crisis in long-term care for the swelling population of older Americans. Over the past decade, the market for long-term care insurance has virtually collapsed, covering just a tiny portion of older people. Home health workers who can help people stay safely in their homes are generally poorly paid and hard to find.

And even older people who can afford an assisted living facility often find their life savings rapidly drained.

Unlike most residents of nursing homes, where care is generally paid for by Medicaid, the federal-state program for the poor and disabled, assisted living residents or their families usually must shoulder the full costs. Most centers require those who can no longer pay to move out.

The industry says its pricing structures pay for increased staffing that helps the more infirm residents and avoids saddling others with costs of services they don’t need.

Prices escalate greatly when a resident develops dementia or other serious illnesses. At one facility in California, the monthly cost of care packages for people with dementia or other cognitive issues increased from $1,325 for those needing the least amount of help to $4,625 as residents’ needs grew.

“It’s profiteering at its worst,” said Mark Bonitz, who explored multiple places in Minnesota for his mother, Elizabeth. “They have a fixed amount of rooms,” he said. “The way you make the most money is you get so many add-ons.” Last year, he moved his mother to a nonprofit center, where she lived until her death in July at age 96.

LaShuan Bethea, executive director of the National Center for Assisted Living, a trade association of owners and operators, said the industry would require financial support from the government and private lenders to bring prices down.

“Assisted living providers are ready and willing to provide more affordable options, especially for a growing elderly population,” Bethea said. “But we need the support of policymakers and other industries.” She said offering affordable assisted living “requires an entirely different business model.”

Others defend the extras as a way to appeal to the waves of boomers who are retiring. “People want choice,” said Beth Burnham Mace, a special adviser for the National Investment Center for Seniors Housing & Care. “If you price it more à la carte, you’re paying for what you actually desire and need.”

Yet residents don’t always get the heightened attention they paid for. Class-action lawsuits have accused several assisted living chains of failing to raise staffing levels to accommodate residents’ needs or of failing to fulfill billed services.

“We still receive many complaints about staffing shortages and services not being provided as promised,” said Aisha Elmquist, until recently the deputy ombudsman for long-term care in Minnesota, a state-funded advocate. “Some residents have reported to us they called 911 for things like getting in and out of bed.”

‘Can You Find Me a Money Tree?’

Florence Reiners, 94, adores living at the Waters of Excelsior, an upscale assisted living facility in the Minneapolis suburb of Excelsior. The 115-unit building has a theater, a library, a hair salon, and a spacious dining room.

“The windows, the brightness, and the people overall are very cheerful and very friendly,” Reiners, a retired nursing assistant, said. Most important, she was just a floor away from her husband, Donald, 95, a retired water department worker who served in the military after World War II and has severe dementia.

She resisted her children’s pleas to move him to a less expensive facility available to veterans.

Reiners is healthy enough to be on a floor for people who can live independently, so her rent is $3,330 plus $275 for a pendant alarm. When she needs help, she’s billed an exact amount, like a $26.67 charge for the 31 minutes an aide spent helping her to the bathroom one night.

Her husband’s specialty care at the facility cost much more: $6,150 a month on top of $3,825 in rent.

Month by month, their savings, mainly from the sale of their home, and monthly retirement income of $6,600 from Social Security and his municipal pension, dwindled. In three years, their assets and savings dropped to about $300,000 from around $550,000.

Her children warned her that she would run out of money if her health worsened. “She about cried because she doesn’t want to leave her community,” Anne Palm, one of her daughters, said.

In June, they moved Donald Reiners to the VA home across the city. His care there costs $3,900 a month, 60% less than at the Waters. But his wife is not allowed to live at the veterans’ facility.

After nearly 60 years together, she was devastated. When an admissions worker asked her if she had any questions, she answered, “Can you find me a money tree so I don’t have to move him?”

Heidi Elliott, vice president for operations at the Waters, said employees carefully review potential residents’ financial assets with them, and explain how costs can increase over time.

“Oftentimes, our senior living consultants will ask, ‘After you’ve reviewed this, Mr. Smith, how many years do you think Mom is going to be able to, to afford this?’” she said. “And sometimes we lose prospects because they’ve realized, ‘You know what? Nope, we don’t have it.’”

Potential Buyers From the Bahamas

For residents, the median annual price of assisted living has increased 31% faster than inflation, nearly doubling from 2004 to 2021, to $54,000, according to surveys by the insurance firm Genworth. Monthly fees at memory care centers, which specialize in people with dementia and other cognitive issues, can exceed $10,000 in areas where real estate is expensive or the residents’ needs are high.

Diane Lepsig, president of CarePatrol of Bellevue-Eastside, in the Seattle suburbs, which helps place people, said that she has warned those seeking advice that they should expect to pay at least $7,000 a month. “A million dollars in assets really doesn’t last that long,” she said.

Prices rose even faster during the pandemic as wages and supply costs grew. Brookdale Senior Living, one of the nation’s largest assisted living owners and operators, reported to stockholders rate increases that were higher than usual for this year. In its assisted living and memory care division, Brookdale’s revenue per occupied unit rose 9.4% in 2023 from 2022, primarily because of rent increases, financial disclosures show.

In a statement, Brookdale said it worked with prospective residents and their families to explain the pricing and care options available: “These discussions begin in the initial stages of moving in but also continue throughout the span that one lives at a community, especially as their needs change.”

Many assisted living facilities are owned by real estate investment trusts. Their shareholders expect the high returns that are typically gained from housing investments rather than the more marginal profits of the heavily regulated health care sector. Even during the pandemic, earnings remained robust, financial filings show.

Ventas, a publicly traded real estate investment trust, reported earning revenues in the third quarter of this year that were 24% above operating costs from its investments in 576 senior housing properties, which include those run by Atria Senior Living and Sunrise Senior Living.

Ventas said the prices for its services were affordable. “In markets where we operate, on average it costs residents a comparable amount to live in our communities as it does to stay in their own homes and replicate services,” said Molly McEvily, a spokesperson.

In the same period, Welltower, another large real estate investment trust, reported a 24% operating margin from its 883 senior housing properties, which include ones operated by Sunrise‌, Atria, Oakmont Management Group, and Belmont Village.‌ Welltower did not respond‌‌ to requests for comment.

The median operating margin for assisted living facilities in 2021 was 23% if they offered memory care and 20% if they didn’t, according to David Schless, chief executive of the American Seniors Housing Association, a trade group that surveys the industry each year.

Bethea said those returns could be invested back into facilities’ services, technology, and building updates. “This is partly why assisted living also enjoys high customer satisfaction rates,” she said.

Brandon Barnes, an administrator at a family business that owns three small residences in Esko, Minnesota, said he and other small operators had been approached by brokers for companies, including one based in the Bahamas. “I don’t even know how you’d run them from that far away,” he said.

Rating the Cost of a Shower, on a Point Scale

To consistently get such impressive returns, some assisted living facilities have devised sophisticated pricing methods. Each service is assigned points based on an estimate of how much it costs in extra labor, to the minute. When residents arrive, they are evaluated to see what services they need, and the facility adds up the points. The number of points determines which tier of services you require; facilities often have four or five levels of care, each with its own price.

Charles Barker, an 81-year-old retired psychiatrist with Alzheimer’s, moved into Oakmont of Pacific Beach, a memory care facility in San Diego, in November 2020. In the initial estimate, he was assigned 135 points: 5 for mealtime reminders; 12 for shaving and grooming reminders; 18 for help with clothes selection twice a day; 36 to manage medications; and 30 for the attention, prompting, and redirection he would need because of his dementia, according to a copy of his assessment provided by his daughter, Celenie Singley.

Barker’s points fell into the second-lowest of five service levels, with a charge of $2,340 on top of his $7,895 monthly rent.

Singley became distraught over safety issues that she said did not seem as important to Oakmont as its point system. She complained in a May 2021 letter to Courtney Siegel, the company’s chief executive, that she repeatedly found the doors to the facility, located on a busy street, unlocked — a lapse at memory care centers, where secured exits keep people with dementia from wandering away. “Even when it’s expensive, you really don’t know what you’re getting,” she said in an interview.

Singley, 50, moved her father to another memory care unit. Oakmont did not respond to requests for comment.

Other residents and their families brought a class-action lawsuit against Oakmont in 2017 that said the company, an assisted living and memory care provider based in Irvine, California, had not provided enough staffing to meet the needs of residents it identified through its own assessments.

Jane Burton-Whitaker, a plaintiff who moved into Oakmont of Mariner Point in Alameda, California, in 2016, paid $5,795 monthly rent and $270 a month for assistance with her urinary catheter, but sometimes the staff would empty the bag just once a day when it required multiple changes, the lawsuit said.

She paid an additional $153 a month for checks of her “fragile” skin “up to three times a day, but most days staff did not provide any skin checks,” according to the lawsuit. (Skin breakdown is a hazard for older people that can lead to bedsores and infections.) Sometimes it took the staff 45 minutes to respond to her call button, so she left the facility in 2017 out of concern she would not get attention should she have a medical emergency, the lawsuit said.

Oakmont paid $9 million in 2020 to settle the class-action suit and agreed to provide enough staffing, without admitting fault.

Similar cases have been brought against other assisted living companies. In 2021, Aegis Living, a company based in Bellevue, Washington, agreed to a $16 million settlement in a case claiming that its point system — which charged 64 cents per point per day — was “based solely on budget considerations and desired profit margins.” Aegis did not admit fault in the settlement or respond to requests for comment.

When the Money Is Gone

Jon Guckenberg’s rent for a single room in an assisted living cottage in rural Minnesota was $4,140 a month before adding in a raft of other charges.

The facility, New Perspective Cloquet, charged him $500 to reserve a spot and a $2,000 “entrance fee” before he set foot inside two years ago. Each month, he also paid $1,080 for a care plan that helped him cope with bipolar disorder and kidney problems, $750 for meals, and another $750 to make sure he took his daily medications. Cable service in his room was an extra $50 a month.

A year after moving in, Guckenberg, 83, a retired pizza parlor owner, had run through his life’s savings and was put on a state health plan for the poor.

Doug Anderson, a senior vice president at New Perspective, said in a statement that “the cost and complexity of providing care and housing to seniors has increased exponentially due to the pandemic and record-high inflation.”

In one way, Guckenberg has been luckier than most people who run out of money to pay for their care. His residential center accepts Medicaid to cover the health services he receives.

Most states have similar programs, though a resident must be frail enough to qualify for a nursing home before Medicaid will cover the health care costs in an assisted living facility. But enrollment is restricted. In 37 states, people are on waiting lists for months or years.

“We recognize the current system of having residents spend down their assets and then qualify for Medicaid in order to stay in their assisted living home is broken,” said Bethea, with the trade association. “Residents shouldn’t have to impoverish themselves in order to continue receiving assisted living care.”

Only 18% of residential care facilities agree to take Medicaid payments, which tend to be lower than what they charge self-paying clients, according to a federal survey of facilities. And even places that accept Medicaid often limit coverage to a minority of their beds.

For those with some retirement income, Medicaid isn’t free. Nancy Pilger, Guckenberg’s guardian, said that he was able to keep only about $200 of his $2,831 monthly retirement income, with the rest going to paying rent and a portion of his costs covered by the government.

In September, Guckenberg moved to a nearby assisted living building run by a nonprofit. Pilger said the price was the same. But for other residents who have not yet exhausted their assets, Guckenberg’s new home charges $12 a tray for meal delivery to the room; $50 a month to bill a person’s long-term care insurance plan; and $55 for a set of bed rails.

Even after Guckenberg had left New Perspective, however, the company had one more charge for him: a $200 late payment fee for money it said he still owed.

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reported that Massachusetts's annual prevalence and incidence rates were 0.91 and 0.071 cases per 100,000 children, respectively.

Lingke Liu and colleagues have described the first case of KHE presenting with thrombocytopenia and Raynaud phenomenon, which may be associated with increased endothelin-1 ( ET-1 ) and reduced eNOS and A20 expressions. This report is published in BMC Pediatrics.

It is already known that KHE is a rare vascular neoplasm affecting infants or young children. The lesions may range from small and superficial tumors to large and invasive lesions with Kasabach-Merritt phenomenon (KMP). No studies have reported KHE presenting as thrombocytopenia and Raynaud phenomenon.

Case presentation:

A 2-year-old male child was admitted to the hospital with right-hand swelling and thrombocytopenia. The right hand exhibited swelling and redness, sometimes cyanotic, which worsened in cool environments and improved with warming. Based on blood report results, Platelet counts were between 50 ~ 80 × 10^9/L. On admission, a physical examination revealed swelling and frostbite-like rash on the right hand fingers. The skin temperature was lower on the right hand compared to the left. Chest CT results on day 3 of admission showed an irregular mass on the right side of the spine.

A puncture biopsy confirmed the diagnosis of KHE based on positive CD31, D2-40, and FLI1 immunohistochemical staining but negative GLUT1 staining. ET1 expression levels significantly increased, while eNOS and A20 expression levels significantly decreased compared to control patients. The patient received methylprednisolone and sirolimus treatments, and his condition improved during follow-up.

They said we reported the first case of KHE presenting as thrombocytopenia and Raynaud's phenomenon. The appearance of Raynaud's phenomenon in this patient may be related to increased ET-1 and decreased eNOS and A20 expression. The range of clinical presentations can make diagnosing pediatric KHE more challenging. Therefore, it is essential to carefully consider the differential diagnosis of hidden KHE in children with a history of thrombocytopenia and Raynaud's phenomenon.

Reference:

Liu, L., Gu, W., Teng, L. et al. Kaposiform hemangioendothelioma presented with Raynaud phenomenon: a case report. BMC Pediatr 23, 574 (2023). https://doi.org/10.1186/s12887-023-04407-1

Not only can oral problems exacerbate lung disease symptoms, but treatment for lung disease can also harm your teeth and gums. Let's talk more about the link between your mouth and lungs and what steps to take for optimal health.

How oral health problems can impact your lungs

Bacterial infections cause oral health problems like cavities and gingivitis. It's not widely known, but you can breathe these bacteria into your lungs on tiny droplets of saliva. Healthy immune systems can help protect most people's lungs from these bacterial invasions. However, compromised immune systems and disease-damaged lungs may not be able to defend themselves. This puts you at risk for conditions like pneumonia or can make existing lung problems worse.

Periodontal disease can also worsen chronic inflammation in lung diseases such as asthma and chronic obstructive pulmonary disease (COPD). With these diseases, swelling in the airways contributes to more frequent symptoms and lung damage. The American Thoracic Society explains that when your gums are infected and inflamed, they send a signal to your immune system that places the whole body on alert. This can lead to more inflammation in the lungs, more symptoms, and potentially more lung damage. Several recent studies have also shown the link between gum disease and lung disease.

How lung disease can impact your oral health

The link between lung disease and oral health goes both ways. Treatment for some of the most common lung ailments — such as asthma, COPD, and sleep apnea— can affect your oral cavity. These medications and equipment can cause dry mouth where your mouth does not produce enough saliva. Saliva helps protect teeth from bacteria and makes you less vulnerable to cavities and gum disease.

Drugs used to treat lung diseases — such as inhaled medications — can also disrupt the normal balance of flora in your mouth, enabling candida yeast to grow and spread. This fungal infection is called thrush and causes white patches or red lesions to develop on the tongue, cheeks, and throat. These sores may or may not be painful and usually go away in a couple of weeks with anti-fungal medication.

Adverse effects of treatment medications combined with systemic inflammation and challenges in routine oral health care put adults with chronic respiratory conditions at higher risk for poor oral health. A study published by the Journal of the American Dental Association (JADA) found that participants with asthma or COPD had higher odds of tooth loss than those with neither asthma nor COPD.

How to avoid lung problems from poor dental health

Maintaining your lung health provides just another incentive for taking care of your teeth and gums. If you're looking to boost your oral hygiene, start with these tips for optimal oral health.

• Brush your teeth at least twice a day, for two minutes each time.

• Clean in-between your teeth daily with interproximal brushes, floss, or a water flosser.

• Schedule regular dental exams and dental hygiene appointments.

When you speak to your dentist or dental hygienist, let them know about your medical history — such as lung disease and treatments — even if you think it's unrelated. They will be able to educate you on asthma, pneumonia, or COPD and their dental implications. Come prepared to ask questions like:

• How often should you visit the office for exams or treatments based on your lung and oral health?

• How can you treat the adverse effects of your medications such as dry mouth or thrush?

• Could you benefit from additional care such as fluoride supplements or antibacterial rinses?

• How can you make appointments more comfortable — whether that's adjusting the chair for easier breathing or using hand signals when you need to cough?

Taking extra care of your mouth is essential when avoiding lung problems. Regular visits with both your dentist and primary care physician will ensure that you can manage issues if they occur. Knowing the connection will keep you, your lungs, and your mouth healthier and happier at the end of the day.

Dr Sharon Robinson, DDS, has offices at Dental Place Cosmetix Spa, located at shop #5, Winchester Business Centre, 15 Hope Road, Kingston 10. Dr Robinson is an adjunct lecturer at the University of Technology, Jamaica, School of Oral Health Sciences. She may be contacted at 876-630-4710. Like their Facebook page, Dental Place Cosmetix Spa.