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.                              

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

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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 hobbies...no 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.  

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. 

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.