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."