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.

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.

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.

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....

Dead...

Birds pecking at their eyes....

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

"For life, with all it yields of joy and woe,

                                     And hope and fear, ‑‑believe the aged friend‑‑

                                      Is just a chance o'the prize of learning love”

                                                   Elizabeth Barrett Browning

            I recently had a phone call from a local newspaper wanting to write an article on a success story from our geriatrics clinic. We reached an impasse when we could not agree on what constitutes success. They seemed to want to hear about a healthy person who had been cured. I told them I really don’t take care of anyone like that—and yet I think that we have successes. Those of us who care for the very elderly and infirm tend to think of success as achievement of a good quality of life.   

            One lady who has been a great example of successful aging is Mrs. Leona Davis. She might not seem like the obvious fit for the reporter who wanted someone articulate and photogenic but she thinks she’s aged successfully. The centenarian humped over in a wheelchair with her wig askew, eyes magnified by cataract glasses, and elephantine legs might appear less than model-like. And, it might be hard to believe that she is successful in light of her failing health, her paucity of money, fears of pain and moving to a nursing home as well as absence of family. Yet it seems like her success lies in her strong relationships.  

            After the few family members she had died years ago, Mrs. Davis did not feel sorry for herself—she grew her own surrogate family. This “family” now cares for her with the devotion of the closest of blood relatives. Through their support, she has stayed in her own home alone long beyond when most elderly would be able to do so.

            Mrs. Davis extended herself throughout her life and consequently, developed relationships that span several generations. For instance, she took in the man who now functions as a surrogate grandson about twenty years ago when as a young man, he first emigrated from Cuba. Though he was a stranger, she was happy to help him get started when she allowed him to board free in her upstairs bedroom until he could afford to pay rent. Now a successful businessman with a family of his own, he comes by weekly to visit and help around her apartment.

            The woman who has filled the position of surrogate daughter is a physician for whom Mrs. Davis worked many years ago as a housekeeper. They grew very close and now, despite living a thousand miles apart, they talk weekly and are able to see each other fairly often. This "daughter" financially supports a home health aide to help Mrs. Davis with bathing, cooking and housekeeping.

            Other friends deliver groceries, provide transportation, help with doctor's appointments and just come to talk. Mrs. Davis gave generously from her heart to others throughout the years and now, she is reaping the benefits of the love she has sown and cultivated. Even now, this woman who can barely get around with a walker and can see only with difficulty continues to give to others by tutoring inner city youth in reading, attending an annual summer camp for disadvantaged children and continuing work in her church.

            This giving attitude has left Mrs. Davis vulnerable‑‑and there have been those who have taken advantage of her trusting spirit. But, when she tells the story about the woman who came in to clean her house and stole four‑and‑a‑half pairs of her shoes, she chuckles, "Now, whatever would anyone do with the half pair of shoes?"

            While this remarkable woman certainly has suffered many trials and tribulations in her life, her vibrant stories downplay them. She clearly expresses that all that she has endured is surpassed by the love she experiences from the lives of those that touch hers. This, to me, is "successful aging."