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. 

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."

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.