Wednesday, December 18, 2013

Perspective is everything

In my white coat
Talking to a family
About their options
     for discharge, for goals, for support at home
Defining my expectations
Directing them down a path

In my white coat
Reviewing the med list
Stopping and starting drugs
    without a backward glance
Meeting criteria and guidelines
Documenting reasons for not

In my white coat
Making medical decisions
Based on my understanding
     of the patient's understanding, the family's
Coordinating other providers
Discussing with social services

How different when you shed the white coat

In my grey sweatshirt
Listening to a doctor
About my loved ones options
   for discharge, for goals, for support at home
Hearing their expecations
Disbelieving of the path

In my grey sweatshirt
Hearing the med list
And it's many, many changes
   trying to remember, to understand
Ignoring criteria and guidelines
Stopping the intolerable side effects

In my grey sweatshirt
Making medical decisions
Based on my understanding
   of the provider, of the person, of my family
Coordinating care because
As family and provider both
     I know more than I want to.

Friday, December 13, 2013


I have a love-hate relationship with euphemisms. There are times that it is nice (and even funny) to allude to something without having to say that ugly word, right? It took me a while to accept the euphemisms related to dying. But now I understand that as long as we say "dying" once clearly, euphemisms can soften the blow of a harsh reality.

However, the use of "placement," when referring to a nursing home move disturbs me. It feels cold and in a disingenuous way, makes it seem as though this is happening outside of any one's control and maybe is even a special honor--"Her Placement." Perhaps this language perpetuates the negative perception of nursing homes, too. Of course, moving to a nursing home is emotionally difficult for all involved BUT as hard as it is to face, active supportive language such as -- "It looks like it is time to move your family member to a nursing home" might in fact be more loving and responsible than "she will be placed."

Tuesday, December 3, 2013

COACH: a window into the home

This part of the curriculum, though short really stood out in my mind as a truly great learning experience. I had started the night before doing a review of my assigned patient’s medications and their discharge summary from their recent hospitalization. The medication list was easy enough to review and jot down, though like many geriatric patients the medication list, including vitamin supplements was extensive. The next portion was the review of the discharge summary. Much like when we saw patients who had been recently admitted the nursing facility the review of the discharge summary allowed us to see what we would want in a summary by evaluating one from the other side. This certainly provided insight into to how to improve my summaries so that they contain everything I would want.

When we got to the apartment complex it was easy to see that the patient, like many of the patients we see regularly in the hospital, was not wealthy. Furthermore, he was housing several other family members in his small apartment complex, which was an added social stressor. My patient, however, despite having multiple health problems, despite having visual impairment, despite having social stressors, had managed to find a means to succeed. His medication list was near identical to the one provided by the hospital, with the few differences being conscious decisions due to identified side effects from his medications. He showed us how he organized his medications and how he managed to remember his upcoming appointments. He was fortunate enough to have a daughter who is a pharmacy technician who appears to be highly medically literate. The patient himself was also quite sharp, which was certainly beneficial. I can imagine without his daughter’s help he would have a much harder time keeping track of his medications, and would likely not be doing as well clinically. The same would likely be true if his cognition was not as good as it was.

Because he was doing so well clinically we were able to pare down on some of his medications, for which he was very grateful. Despite this he still had a toolbox full of pill bottles to take on a daily basis. We were fortunate in seeing a highly motivated patient who despite having a tough home situation was able to overcome his adversities. However this one patient might be more of an exception than a rule. How many patients keep coming back to the hospital because they can’t understand how to manage 20+ medications? Or lack the social support structure needed to take care of themselves.  Ultimately, what made this visit memorable was not just the visit itself, but the multiple permutations of possible visits and the multiple challenges each possible permutation might present. 

Joys of Geriatrics

Geriatrics is a crucial rotation to have in residency training.  I’m glad that residents can start taking it earlier than their third year now.  The rotation and the attending physicians involved really make you step back and look at the whole picture.  So often I think that we, as residents, get caught up in the minute details and linguistic web of describing someone’s coronary anatomy, or quantifying how much air they can blow out in one second (which is still important); that we lose sight of looking at the patient and their progression through a lifetime.  Geriatricians are emphatic about looking at the whole patient, which I think is a quality any physician should aspire to possess.

                Not only is this broad view incorporated; but also paying attention to the subtlety of a patient’s presentation.  The tempo of their speech.  The way that they walk before sitting down.  Small changes in behavior patterns such as beginning to eat less.  Presentation of common diseases is often subtle, and not textbook when dealing with elderly patients.  A good example of this is depression; which is why it is so important to screen in this population.  Physicians have to be thorough in this population, otherwise treatable disorders can get missed.

                Overall, I enjoyed my time spent on the Geriatrics rotation.  Not only for the reasons and lessons above, but I believe that it made me a more thorough and caring resident.  There was an element of continuity in the nursing homes that I enjoyed.  Regrettably, I will not be able to see how those patient’s do over the next coming months.  For a rotation that I thought I was not going to enjoy, I was certainly both impressed and humbled; not only by the physicians that I worked with, but also by the patients that allowed me to participate in their care.

-- Mitch Tener

Monday, December 2, 2013

Shocking news!

I had a medical school gerontology professor who would always open his talks in a dramatic, hushed tone saying, "I have a secret to tell you . . . none of us are going to get out of here [this life] alive."  It is an undeniable fact.  The billions of humans who came before us all have had the same fate.  What's surprising then, I suppose, is that the assertion sounds so bold and almost startles us.

The comment could compel you to:
A) Live in the fear of the unknown after our earthly bodies fail us, or
B) Make the life you have as lively as possible

I choose B, and I like to think that as geriatricians we choose B for our patients, as well, by championing for quality of life instead of single-mindedly waging war on death.  With that in mind, my professor's declaration invokes not alarm, but a smile whenever it comes to mind.

Tuesday, November 19, 2013

When fixing it ain't worth it

Like most physicians, I was initially drawn to the field of Medicine due to the profession’s blend of compassionate care and the intrigue of very nerdy science (human physiology/pathophysiology).  It is one of the only professions that allows one to apply scientific knowledge to relieve an element of human suffering. The majority of our training teaches us to identify a disease processes and "fix it" with the best "tools" available. Unfortunately, the "tools" we use as physicians all come with a long list of side effects and, at times, unwanted outcomes. During my Geriatrics rotation I experienced a different paradigm of practicing Medicine, which was refreshing. The ultimate goal remained the same; to alleviate a patient's suffering with the tools at hand. The difference in the approach was simple, "is it worth fixin'." Ultimately, a patients quality of life should always be the focus of our treatments. At times the possibility of fairly common side effects can outweigh the benefits, especially in the elderly.

While in clinic or visiting a NH, I found myself drawn to suggest an more aggressive therapy when presented with most clinical problems. I was able to recognized this near reflexive response I have developed during my training. It was nice to take a step back, evaluate the long term effects of the said therapies in the Geriatric population and ask the patient...... is this treatment worth it?  Many times the standard treatment recommendation just simply wasn't.

-- Benji Mulloy

Sunday, November 17, 2013

The resident made a save on house calls this week

The patient was improving beautifully after back surgery. However, the object of our intervention ended up being a geriatric dog who appeared dazed and frozen in front of our car. The resident hopped out and picked up the gentle little fella. While it took the grateful owner a while to drive to our location, the refreshing pause in the crunchy leaves and warm autumn sunshine on a busy day offered an unexpected reward for making house calls.                              

Tuesday, October 29, 2013

Observations of Aging

My mother had a friend who developed Alzheimer's. This friend of hers was unmarried and had lived independently and was loosely in touch with her one daughter. Somewhat strangely my mother's friend had purchased insurance through a door-to-door salesman that covered long term care facilities. It was fortuitous that she had purchased this insurance because within a few years she had developed Alzheimer's disease and needed 24 hour care. My mother drove an hour each way to take her friend to breakfast once a week. She continued this tradition long after her friend did not remember her name and did not know who she was. My mother continued this because she sensed that her friend was at peace during these visits and it provided a change in her day to day routine. She continued these until her friend was unable to leave her facility due to physical decline and then brought breakfast to her although towards the end she did not eat much. I know all of this because sometimes I went with her on these visits and my mother's friend became dear to me too.

My own family has been touched by dementia and its hand has often been heavy. My Grandmother showed early signs of dementia but was sadly killed in a car accident before her disease progressed. Her sisters also developed the disease which eventually took their lives. More recently one of my uncles has developed dementia but through testing he was found to have Frontal-temporal dementia. In his case my Aunt is his sole care-taker and this has been a difficult role to fill for her. She has an amazing number of challenges especially because my family are all very handy and have woodworking and mechanical skills and thus there are many (now) unsafe items in their house which of course my Uncle is drawn to as his tools have been an extension of himself for all his life. My aunt works endlessly to redirect him when he becomes frustrated often not sleeping well because he is active and restless during the night. He has required more and more assistance with his everyday needs.  They live in a remote area and one time she related to me that at times when it has just been the two of them for a prolonged periods of time she wonders if they are both crazy. She is a very dear person and it is difficult to witness this progression.

I am lucky enough to have also have family who have lived into their 90's and lead productive lives. My Grandfather has led by example his entire life. He was in World War II and was a pilot. He had been shot down and his plane had landed in Switzerland. He returned home and obtained an engineering degree and spent his career in architecture but was also active on the water board in his community which is something he remained active in until his last years. He was also very devout and played an instrumental role in his church. He remained very sharp his entire life but he did unfortunately suffer a fall and struggled with a weak heart and failing kidneys but remained dedicated to his family, his church and to God his entire life. My Grandmother had been his caretaker during his last several years and had needed to take over the responsibility of driving at some point. She made all his meals and managed his house for him. We all know if it had not been for her my Grandfather may not have lived as long or as well as he had.

In my own community I became friends with a remarkable gentleman. The day not so long ago I sat down next to an older gentleman who had brought his grandchildren to the park. One of his grandchildren knew my son from kindergarten and they began playing together. This led to a remark which led to a conversation and before long I knew this gentleman's life history. He has worked in "beverages" his entire adult life and he retired from Coca-cola about 10 years ago. I asked what he has been doing in his retirement and he replied that for the first 5 years he and his wife cared for his ailing mother-in-law and that she had passed away 5 years ago.  At about this time his wife had begun showing signs of dementia and was diagnosed with Alzheimer's. He cared for her at home until one year before she passed away. He had some very difficult times caring for her as her behavior became more unpredictable and she suffered falls leading to fractures and hospitalizations. He finally could not care for her at home and she was placed in a nursing facility where he visited her every day. He said it became more difficult as time passed to make these daily visits as she became more withdrawn. She did die about one year prior. He was tearful as he said this but he straightened and returned to watching his grandchildren play. He said that in the last year he has slowly began traveling which is something he and his wife had always wanted to do. He has remained active in his community and cooked up award winning chili once a year for a boy scouts fundraiser. He drove down to visit once every couple of months and stayed active in his children's and grandchildren's life. Amazingly he is very involved in my son's kindergarten class (despite the fact he lives several hours away) - and most of the kids know him.

I have been so fortunate to be able to learn from those around me about growing old gracefully or about living with disease. I am so lucky to have all these people in my life and their experiences have deeply influenced who I am today and for this I am so grateful.

Submitted by Casey Kimber, DO

Tuesday, October 22, 2013

Do you want to blog with us?

Thank you for visiting Paging for the Aging.

For those of you who visited our table at the Reynold's meeting in beautiful Coronado, thank you for your amazing support!

We would like to extend an invitation to those of you at other institutions to guest post, collaborate, and just increase the footprint of Geriatric Medicine! Please be in touch if you are interested.

Tuesday, October 15, 2013

Resident Post: Maykol Postigo

Throughout my geriatrics rotation I have met elderly individuals from all walks of life.  While they have taught me many lessons, there is one that sticks out above all else….compassion and patience are some of the best medicine a physician can offer.  

Mrs. S is a pleasant 92 y.o. nursing home resident.   Upon arriving to the nursing home I was directed to her room to evaluate her new onset abdominal pain.  According to the nursing staff, Mrs. S had been having excruciating abdominal pain all night long and yelling out to the nurses to come help her.  When I walked into her room, Mrs. S was laying in her bed, still dressed in her nightgown and reading a book.  I asked about her abdominal pain and she began to describe a very severe pain, but couldn’t give me any further details.  As I proceeded through the history and physical, Mrs. S continuously interrupted me to tell me stories about her family, particularly her grandchildren.  You could see her eyes sparkle with pride with each story she told.  She also told me about her deceased husband.  Sitting next to her nightstand was a photo of the two of them which she proudly admired.  She felt lonely without him and prayed for the day when they would be together again.  She also began to ask me questions about my family and wouldn’t proceed with the interview unless I told her about myself and my life growing up in Peru.  It truly gave her joy to hear about my family and my aspirations in life.  

By the time my history and physical had finished, I had spent nearly 1 hour sitting by her side.  I was touched by her life stories and experiences.   I told her that I needed to finish our visit so that I could continue to see other nursing home residents that day.  I asked her again to describe for me her abdominal pain.   She merely looked up at me with a coy smile and said “What abdominal pain?  I feel fine.”  It was at that moment I realized that you can treat a patient’s symptoms with modern medicine, but it is just as important to treat their heart and soul.  

Resident Post: Kinza Shamsi

"She complains about everything.  Mrs. D, do you need pain medicine, "yes my hip hurts so much."  This was the nurses's assessment for a patient at one of the nursing facilities I visited during my geriatrics rotations.  She told me that the patient appears comfortable and is usually wheeling herself around perfectly content but anytime someone asks her about pain or asks how she's doing, she always gives an exaggerated list of complaints.
During my encounters with Mrs. D, she gave me a similar report of pain.  When I asked her if the interventions we made to control her pain have helped, she responds, "I don't know, it's all the same."  When asked if she is able to make it to the bathroom on her own, she states "no I need help."  And again I think back to the nurse who reports with a smile on her face "she uses the bathroom on her own ALL the time."
I can't help but wonder why this patient seems to be exaggerating her symptoms, or is she?  What I realize though is that she is unhappy with her current state and wants nothing but to go home.  She doesn't seem to realize that the more she engages with the interventions for which she is here, the sooner she will be able to go home.  I also wonder if her cognitive deficits are so severe that she is unable to remember her daily activities.  I wanted to hear something original from her.  Some way to connect with her and make her realize that I cared.
I asked her what she does at home, what are her response..."Do you like gardening?  Ah hah...her face lit up, her eyes popped open and she looked up at me and finally make eye contact.  She said, "yes I do gardening at home."  I told her that my mom also likes gardening.  She started talking to me about what she plants and that she loves watching something grow from a seed and then be able to use it.  and for the first time, I saw her smile at the thought of her garden and I could see in her eyes that she was imaging herself in it and you could almost see the vegetables in her garden though her eyes.
All the patients that we care for in a nursing facility are people and sometimes in our rush and in our own stressors, we forget to stop and chat with them as we might with a younger patient who presents to clinic.  It's so much easier to present that "the patient said 'I don't know' to all my questions."  We quickly listen to their heart and lungs, disregard their "complaining" and say, "I'll let your nurse know."
Perhaps we should remind ourselves more often that these quiet figures scattered about the nursing home on their wheelchairs with their heads slumped down are...people.  People very much like ourselves who still have fondness for happiness, love, and satisfaction in life.  Taking 2 minutes extra to connect with them and recognizing their unique personhood gives them joy and also helps as practitioners find satisfaction and meaning in what, sometimes, becomes our daily chore.
Mrs. D certainly brought warmth to my heart that day and I hope I brought some to hers even if it was only to provide her a reason to retrieve a memory and imagery that was already tucked away in the corner of her brain.  

Monday, October 14, 2013

Babies are therapeutic. Caring for someone who is so completely helpless gives rewards in being able to sustain another even when it is exhausting. The tender love of families for their children is moving. The same is true at the other end of the spectrum. While most of us would not choose to go back to that baby-like state, many of us will. Alzheimer disease is common and Alzheimer disease causes dependence. And dependence can be beautiful. I have seen the loveliest scenes from tired family in the act of caring for a patient with Alzheimer disease: the candy that made the anxious lady smile, the gentle washing of a dirty bottom, the tender pedicure of arthritic, crumpled feet, the handling of a friendly dog. So many caregivers are selfless heroes minimizing their work for the joy of recompensing the ones they love. Caring for the elderly is therapeutic. 

Wednesday, August 28, 2013

Resident Post: Brad Scheu

"He would never have wanted this." Through the tears, my patient's family were clear their father would never want a breathing machine to sustain his life, if even temporarily.

The endotracheal tube was secured 25 cm at the teeth. It had been that way for about 2 hours, but I'm certain it seemed like an eternity to the two daughters of Mr. S. when they walked into the ICU room that morning at about 7:30am. Although Mr S. had previously been well sedated, he quickly started coughing upon his daughters entering the room. Their tears echoed his disdain for the situation.

As a former high school teacher and coach, Mr S had lived a full life. The ripple effects of this were evident in the love his daughters were showing for him. He had undoubtedly touched the lives of many through his teaching, in and out of the class year. As the years went on, however; so did his mind. Although his body was relatively young at 92, his mind was not. Alzheimer's, a difficult disease and form of dementia, had sent in some years ago. The disease progressed, as it normally does and activities of daily living became more difficult. About 2 weeks ago, he got out of bed quickly to use the restroom, had a mistep, heard a pop, and fell to the ground. After family had brought him to the emergency room, it was discovered that the pop was in fact a broken bone in his left hip.

Several days later, the patient was having difficulty with pain and confusion. After undergoing a surgical repair for a broken hip, his post operative course was proving to be more complicated than the procedure itself. Days after the operation, his groggy mental status and severe pain led to difficulties eating and swallowing. This common set up for aspiration leads to more problems. Unfortunately, he developed respiratory failure in the middle of the night, and was transferred to the ICU. In an emergent response, the patient was intubated so that a mechanical ventilator could assist his breathing.

Although family had been contacted in the middle of the night prior to their father going on the breathing machine, nothing prepared them for the reality of the situation when they walked into the room the next day. Hours later, the patient passed comfortably after family members elected a comfort care approach.

Unfortunately, this is not an uncommon situation in today's healthcare system. Healthcare providers performed quality care. The family was present, caring, and supportive of their loved one. The patient, perhaps the most vulnerable, presented for help in a time of need. So how did Mr. S. find himself in a situation he would never have wanted?

Mr. S. had never filled out an Advanced Directive.

Monday, July 29, 2013

Resident Post: Jessica Lee

Front-Temporal Dementia:  Losing your humanity before your life.

She used to be a librarian.  She wore business suits to work every day.  She never left home without her panty-hose or her make-up.

Hope for the Hopeless

She moved to be closer to family 18 months ago.  Mrs. U and Mr. U lived independently for 70 years together, but at the age of 94, Mr. U was falling and needed more help from family.  So they packed up and moved closer to their son.  Mr. U continued to have the same problems: heart failure, COPD, frequent falls.  Initially, things were pretty much the same.  They lived in assisted living and there were meals provided, medications given, social activities to attend.  Mr. U enjoyed Bridge and Mrs. U watched and chatted.  Mr. U still had frequent visits to the local hospital, and with each one, he was a bit more frail.  Mrs. U was less able to care for him.  They stopped attending social events & Mrs. U started to have more health problems of her own.   It started with a short hospitalization for an infection.  She had increased confusion during that hospitalization and there was initial concern she might not be safe to go back home.  She was given a diagnosis of Alzheimer’s and started on some medication.  She was told “you are doing great”.  She went back to the assisted living facility that she shared with Mr. U (when he was not in the hospital).  She no longer wanted to attend meals at the shared dining hall.  She previously walked the halls passing the menus, and now could hardly find the energy to get out of bed.  She had dizziness with standing.  She had twelve medications when she previously was on three.  She stopped coming to her son’s for dinner.

Mrs. U’s son was quite concerned and brought her to the geriatrician.  Her answers to questions were quite simple. 

“What do you feel like is going on with your memory?”

“I am becoming nothing.  Everyone keeps telling me that I am doing well, but I am becoming nothing.  Please help me.”

“Do you feel you might be depressed?”


“Do you feel sad more days than not?”


“Do you feel worthless?”

“Yes.  I can’t even get to Mr. U when he needs me.”

“Do you feel satisfied with your life?”

“No.  I am becoming nothing.”

Mrs. U scored nearly perfect on her memory test.   Her medications were simplified with discontinuing five of them.  She was started on anti-depressant and before she left, she smiled a hopeful smile.  Time will tell if this regimen will work, but the simple thought that something might help already seemed to have a positive impact.

Resident Post: Eyad Reda

Geriatrics was my first rotation as an intern. The feedback that I got from some of my friends whom are doing residency here in the states was that it is an easy rotation to start with, and that it will help me to smoothly blend into the “residency” lifestyle. Although this was true, none of them mentioned how important “Geriatric medicine” is, and should be, to our future practice as physicians.
By 2030, the percentage of people >65 years old will be around 20% of the general population here in the US, that means one in every fiver of our patients. With this, comes the need that every physician should know the common health problems that are unique in this age group. Things that we do not pay attention to in our general patient population, like the number of stories in the patient’s house, might pose a major health risk for an elderly patient living alone.
When I look back now at my first month, I can say that I am thankful that Geriatrics was my first rotation. With the help of highly passionate attendings and fellows, I learnt how that with the elderly patient, there should be different approaches to the medical encounter compared to younger patients. Asking simple questions about their daily lifestyle, habits, fun things they do, (things we do not usually focus a lot on), will give us tremendous details about the risks and the possible interventions that we could do to improve the quality of life of our elderly patients.
I will not say that I will miss searching for information about my patients in the “huge” paper charts in the nursing homes I went to, but I definitely will miss learning from physicians whom practicing medicine for them is not only about diagnosing and prescribing medications, but rather, taking a further step into analyzing the psycho-social dynamics of the diseases that an elderly patient have and trying to work on addressing these issues in the same  level of importance as their diseases’ pathophysiology and treatment.

Resident Post: Hieu Doan

Aging exempts no one. Unfortunately, some of the elderly developed more health problems and physical declines than others.  Elders with such significant impairments required various types of assistances included their basic activities of daily living.   These tasks were not always being accomplished safely at home especially when their sons or daughters had children and a full-time job.  Despite this concept, in a way, society continues to be biased about the placement of one’s parents into a nursing home as a disgraceful act.  Being a medical student then a resident in geriatrics rotation, I learned to acknowledge the burden of caring for the elderly rather continued with my previous superficial judgment.  Ability to care for one individual with multiple medical problems and functional declines beyond the financial burden, it included physical and emotional obstacles.  Dressing, eating, ambulation, transferring, hygiene, medication management and etc.  could be beyond one’s person ability.  Thus, the only best available option for some family in caring for their parents or other immediate family members was placement in long-term nursing home.  Such decision was not easy as one may expected.   I struggled with this idea as imagined placement of my immediate family members in nursing home.   I saw closed doors along the sides of the hallways and the empty lounges with occasional one to two occupants in a facility. In concurrent with complaints of not being heard, not being assisted promptly and the abuse in the long-term facility demonstrated in the media worsened the objectivity of this topic.

 I am hopeful for changes or resolution in some of these concerns.  The business of long-term nursing home should be asked to increase the ratio of nursing-staffs to long-term care residents in its facility.  This is the initial step to improve care and fulfill the rising demands of our growing elderly population.  

Resident Post: Colleen Brown

My patient took obvious pride in her appearance, displaying on her right hand a beautiful diamond ring. She wore hosiery and her hair was carefully curled, her blue suit pressed. 

Her daughter sat next to her, exhausted from the preparation for the doctor's appointment. "She wouldn't leave the house until we found her brown and white purse." They searched high and low, eventually finding it in the kitchen cupboard.

Tears brimmed in the patient's eyes as she struggled to answer the date, the season. She did not recall the apple, table, or penny.  She raised four children while working as a registered nurse, delegating responsibilities in a busy surgical unit. Her daughter had taken her on tours of assisted living facilities. She had also taken her mother's car keys. As the appointment was ending, we discussed the most likely diagnosis and agreed on a trial of medication. 


The patient resolutely completed her sentence, long after the test was over, and handed it to me.

It read "I have faith."

Wednesday, June 12, 2013

Resident Post: Maharshi Bhakta

I did Geriatrics last month as an Intern and I am elated for having this rotation earlier on in my Residency. Topics and discussions that we had in Geriatrics were unique and separate from rest of the rotations I did as an Intern. For example, when seeing a patient in the clinic we automatically assume everyone is going to live to be 100 years old. This is certainly not true however when considering screening test it rarely comes to mind to evaluate the life expectancy of the patient and whether the patient will be able to get the treatment if screened positive. Also, after completing Geriatrics, I find myself evaluating patients ADLs and IADLs not because I never learned them in medical school but I never grasped the importance and relevance of that affecting the patient's health and social situation.  During the clinics with Dr. Hayley and Nursing home visits with Dr. Kalender-Rich, I had opportunity to focus on issues pertaining to geriatrics such as driving ability, dementia and incontinence. I feel like I became more clinically astute in assessing and managing those issues.  

Resident Post: Cipporah Gordon

The reality of Aging

 The realization we are all going to be “old” someday, G-d willing, is usually a thought placed under layers of other more eminent and relevant ideas. However, when walking through a nursing home this thought quickly surfaces faster than the speed of light. One notices each resident’s room is adorn with photos of the very lives they created generation upon generation. There most always is a black and white photo of a man in military uniform that catches your attention, and can be used as a starting point for conversation.
The elderly individual varies in their ability to interact with you; some diagnosed with Alzheimer’s dementia and are unable to accurately answer questions, but some elderly individuals are in good health and can give you their whole life story, whether you ask for it or not. Strangely enough both of these individuals impact you the same. The deep wrinkles on their face are indicative of the many expressions felt in their lifetime from happiness, sorrow, fright, to excitement, and you truly begin to wonder what kind of life they had prior to coming here; how many kids? Homemaker or serviceman? Do they remember the depression and WW2? the Holocaust? They become a non-published version of a history book in their own right.

Further, the elderly person with Alzheimer’s dementia gives you a few extra thoughts to ponder. Thoughts such as, what a challenge for their family to see their loved one without the very memories that makes them who they are… and what if this would happen to me? Or someone dear to me? This is truly a hard disease not only for the patient but for those who love them.
It is the circle of life to age and to die, yet feeling like one is going to “get old” one day seems unreal and I am certain it did to the very people I saw. Maybe living our life like we are “aging”  each day would afford us the perspective of doing the “things” that really matter to us,  and with those that matter to us most. For certain, we are all on a time clock never knowing when the alarm will go off, only hoping it will not be today. So to age is a blessing- It was an invaluable experience to have met  these individuals over the course of my geriatric rotation and I can confidently say the realization I will be “old” someday does not have as many layers covering it as it did 4 weeks ago.

Tuesday, May 7, 2013

Resident Post: Pooja Bhadbhade

The last month of Geriatrics was surprisingly rewarding.  I get so used to the fast pace of inpatient medicine, so shifting to Geriatrics was a new concept because I realized you have to approach the patient differently.  I quickly realized that you ask different questions and look out for specific things when seeing a geriatrics patient.  For example, I never thought about asking about ADLs or IADLs when doing an H&P, but knowing this will help guide your plan for a geriatrics patient.  In addition, one concept I will find useful is the concept of prescribing cascade which involves prescribing medications for symptoms caused by other medications, and I didn't realize how often this happens until I came across this concept.  Also, I realized the importance of considering a patients age and life expectancy when it comes to treatments and screenings.  It's easy to get in the routine of common recommendations, but it's important to step back and look at the patient as a whole and consider where they are along life's continuum. Finally, it dawned on me that growing old is not easy because many patients are limited on what they can and can't do and things that define them or activities they have enjoyed their whole life may not be possible anymore due to their functional status and as a person who is active and constantly on the move, I can't imagine what it's like not to be able to enjoy those activities.  However, almost every patient was accompanied by a loved one or someone who looked after them who worked at making their elder comfortable and safe which is encouraging.  

Resident Post: Alan Doty

As I look back on the last four weeks on the geriatrics rotation, I am amazed at the complexity of the medical management involved in the elderly patient care. As a physician, we have the unique experience to see the many aspects of care from the family members involved, hospitals, long care facilities, home health, and even hospice and the absolute importance in the effective coordination involved in managing all of the aspects of care. During my time time on this rotation, I had the opportunity to visit with many patients and families, all of them so welcomed the care and I never saw any loved one express anger or frustration, even with sometimes devastating diseases that they were dealing with. The history and experience that the older generation has is so important. Just to sit and listen to there stories is amazing. Not only do the benefit from having someone to talk with and relay the experiences, but the insight and value of hearing those experience can not be measured. My greatest hope is that we, as physicians, don't loss the ability to spend time getting to know our patients and their families.

Saturday, April 13, 2013

Resident Post: Matthew Butler

Starting my geriatrics rotation, I wasn’t sure what to expect.  Many of the people we care for in internal medicine are by definition “geriatric”, so how could this rotation really be much different, right?  What I discovered during this rotation is that sometimes taking care of your patients doesn’t mean simply mean ordering the right tests, making the correct diagnosis, and giving the evidence-based medical therapy.  There is more to that, especially when dealing with older patients.  I found myself looking past the basic medical evidence and instead thinking about what would truly be best for each patient.  Maybe that blood pressure medicine, strict diabetic control, or allergy medication is doing more harm than good; or does the benefit of ordering that invasive test really outweigh the benefit in my frail 82 year old patient? No, not every 80 year old is the same regarding their functional status and treating each patient the same is bad medicine. 
I also came to realize that looking past vital signs and lab test is necessary to really care for my patients. When someone is falling at home or having a difficult time caring for themselves, the answer is oftentimes not simply in the “results” section of the chart.  It is buried in the patients’ history and their home situation. Who is there to provide care at home?  What can be done to make your living situation safer? Are there things we are prescribing that are actually making this worse?  These are the questions I had to ask myself.  In essence, I re-discovered the “art of medicine” and re-focused my treatments to the individual, which is so vitally important in the geriatric population. 

Tuesday, April 9, 2013

Resident Post: Jennifer Schrimsher

"A place for everything and everything in its place," she said, as if her grandmother's maxim would somehow save her husband from his fate.

The questions the doctor asked further solidified what she had feared. She couldn't bear to watch it being committed to record, "There you go, with the typing again. Do you really have to write this all down?"

Her schoolmarm demeanor would falter at times. A dab of the tissue beneath her glasses, "I go through a lot of these, these days."

His adulthood was slipping away. Not into old age, but adolescence. His ornery boyhood charm was evident. A former college professor, his specialty was computer science. He could no longer remember how to operate his own.
She clutched her tissue.

The dirty clothes hung with the clean. She knew by the way he folds his sleeves.
The accidents found in the hamper. 
The nest egg squandered unbeknownst to her.
The stop sign he ran on the way. "Well there was no one coming."
He smiled.
She dabbed.

His toenails had become unsightly. She had mentioned they needed trimmed that morning. He had complied. He took off his socks to show his handiwork, nails cut to the quick.
He smiled.
She dabbed.

As she broached the subject of the future, the retirement village by their son, the living will... she clung to his arm. His "big, strong" arm, she said. The arms that had built their house, helped raise their children, protected her for so many years...
He smiled.
She dabbed.
And she dabbed again.
And he just smiled and took her hand.

"It'll be okay."

Wednesday, March 13, 2013

Resident Post: Tamim Mahayni

As I reflect on my geriatrics experience, I’m left with a sense of amazement to the strength of the spouses and families I met throughout the month.  Every patient I had the opportunity to visit was accompanied by a spouse, sibling, or other loved one that was able to recount the activities of the past year in a detailed manner leading to a meaningful visit for both the patient and physician alike.  Never did I encounter a family member frustrated with the task of taking care of their loved one, and for this reason, it is essential for the physician to provide gratitude every visit to the loved ones.  I can only imagine the degree of difficulty it is to manage the daily life of an elderly family member with cognitive deficits, and the families I met do this on a daily basis.  I can only hope that I’ll be able to provide the same level of care to my loved ones when the opportunity to do so arises. 

Just Say It

Older adults often need a treasure map to navigate the medical system, a map that rather than leading to treasure,  actually just leads to the truth. They, like the rest of us, deserve to know the truth about their medical care and their functional status and their prognosis. They deserve to know.
I recently heard a classic example:
Mrs. K went to her optometrist and was told her eyesight had worsened and now would prevent renewal of her license… unless her cataracts were removed.
The cataract doctor said her cataracts would prevent renewal of her license… unless a specialist performed a procedure.
The retina specialist (after months of waiting for an appointment) said her eyes would prevent renewal of her license… period.
A horrible thing to hear. An isolating, dehumanizing, depressing thing to hear.
But she finally has an answer. She can finally plan. And she isn’t being sent (mind you, driven by others becauses he can’t see well) all over town to be repeatedly given a glimmer of hope when one doesn’t exist.
She finally has an answer. And she finally has a plan.
Just Say It…

Resident Post: Leona Graham

The one thing that unites all human beings, regardless of age, gender, religion, economic status or ethnic background, is that, deep down inside, we ALL believe that we are above average drivers. 
-Dave Barry, "Things That It Took Me 50 Years to Learn"
I recently sat through a clinic appointment where the staff physician had to tell a patient that it was not safe for him to drive anymore.  The patient had been an Army Infantry officer in the Korean War, he had worked into his 70’s and now he was having memory loss.  He was very angry at the news, and I could not help but think about how I would feel when not be safe to drive.  I imagined that I would feel the same way.  What does driving mean to us?” Words that come to mind include: Freedom, Independence, and Being Grown up, Going places, Excitement, Fun, Adventure, Protection, and Status.
As we age, our physical faculties diminish; we can lose now only our hearing, eyesight, focus, processing and reaction time and physical strength.   When we have to stop driving because it is not safe anymore we lose the intangible things including a part of our identity.

Friday, February 15, 2013

Resident Post: Luke Amos

The last place I thought I would find inspiration for my geriatric rotation reflection was my Twitter feed.  The irony being that the majority of adults over the age of 65 are in all probability still foreign to social media.  But, that’s exactly where I found my motivation.  During my daily surfing/procrastination I came across a wedding announcement, of all things, that wholly underlined the words of one attending, “age is not a number”.  Over this month I’ve gotten to see up close and visit with patients in the clinic, skilled nursing facilities, and other clinical settings that resemble Ms. Bryant (97) and Mr. Haire (87) [see hyperlink to article above].  From the 92 year old gentleman who still smoked his daily cigar and drank his daily beer and slyly requested his bath aide be female to the truculent 85 year old retired nurse who pointedly required that all of her medications be laid out and explained.   
 It’s a poignant and heartwarming story that truly shows many things do not change as we age.  Nowhere is this clearer than in Mr. Haire’s unabashed honesty when it comes to bearing his true feelings.  Best expressed as, “I can attest that it doesn’t get easier even in advanced age.” I also truly appreciate the fierce loyalty and independence that comes across with the line, "The bride, 97, is keeping her name."  And together the bridge and groom being initially reluctant to be cast as a “couple” in their retirement community, as the article points out, a “couple” being a widow and widower who have dinner together.  The whole scene tepidly brings to mind first loves and high school gossip.  A reminiscence that at 90 is just as real and at times painful as it is at 16.   The lesson of age not being a number will be the life lesson I take away from my month on geriatrics.

Tuesday, February 5, 2013

Resident Post: Shaundre Brown

"In youth the days are short and the years are long; in old age the years are short and the days long." --Nikita Ivanovich Panin

As I near the completion of my geriatrics rotation, I have the opportunity to reflect on the many lessons that I have learned. What a great opportunity it has been to see the other side--to see what happens when our elderly patient with CHF/COPD/etc with limited resources leaves the hospital. As expected, discharge planning, particularly for the geriatrics population, is a key focus for the medical team starting at the time of the hospital admission. I have taken care of so many patients where I have wondered how they managed to continue to live at home alone. In our discharge planning, we often coordinate with PT/OT, speech and social work teams to help develop the best possible discharge destination for the patient, many times for our geriatric patients, we decide that place should be a nursing facility, either short or long term. Ideally, there is good communication between the medical team, patient, and family during the course of the hospital stay. A few months ago, I had a patient, Ms. X, who had end stage heart failure as well as a history of schizophrenia. She would come in to the hospital and it was "obvious" to all of the medical team that she "clearly" belonged in a nursing facility. She required help for all of her IADLs. She would feed herself but basically needed help for almost everything else. She would come in and we would tune her up. Then, everyone would talk to her about going to a nursing home. She always said no. Psych was consulted--yes, she had capacity. I saw her when her disease was at the very end stage, but according to the records this had gone on for many years. Some of us on the team would say "how can she continue to live that way?" or "why won't she let us help her?". One day she told me her reasoning. She said, "I ain't got long. What time I do have I wanna be at home". Very plainly, she laid out her goals for me, She told me that she did not need much, but she just wanted to be home. One of my attendings on geriatrics shared with me that our "frail" geriatrics patients actually do quite well at home. She said that I would be surprised to see how these patients can often even thrive when in their own environments. I saw many of these  patients in the geriatrics clinic--my attending was right. Hopefully, we can all continue to do our best to respect the wishes of our patients. It's so important to many elderly patients to spend their last days in their own environment. We as the medical team should exhuast all efforts to try to have patients at home whenever possible for as long as safely possible. We should hope that one day someone else will do the same for us as our years grow short, if we are so blessed.

Resident Post: Christi Bartlett

A few weeks ago I went to see an elderly patient with severe dementia who was a WWI veteran.  He was in a pleasant mood during my exam and on my way out the door I thanked him for his service to our country.  His face instantly changed and he began to weep quietly.  I could only make out a few of his words...

Laying there....


Birds pecking at their eyes....

And then he broke down.  Inconsolable.  There are some memories that even Alzheimer's can't erase.