Understanding the disease

How many times have you been at church or social functions and witnessed that “little old lady” that is running the show? From party planning to organizing the Christmas plays to cooking dinners for 30+ people, my grandmother has always been that person.  I often compared her to geriatric patients in my medicine clinic and thought, “how does she do it?”  No one in my very large family was prepared for the day when she suddenly was no longer able to juggle it all.

My grandmother had a very difficult 2013 that all started with her having back surgery.  She had undergone multiple back and other joint surgeries in the past and always seemed to be back on her feet within days (so everyone thought this time would be no different).  Unfortunately, following a very lengthy procedure, my grandmother woke up and really didn’t know anyone.  Her husband of 50 years, her 4 children, the multiple grandchildren, and even great grandchildren that she often babysat, were only intermittently recognized.  At first, I assumed (from 100s of miles away) that she just had hospital delirium.  I received calls almost daily from my very distraught mother asking “what is wrong with her?” and “is she going to get better?”  The longer my grandmother was hospitalized and as the confusion persisted, the less clear those answers became.  The decision was made to take her home after about 2 weeks as we all hoped that she would improve after being back home in her normal environment.  This unfortunately was not the case, she actually declined – screaming all night in pain, became incontinent of stool and urine, and completely exhausted my poor grandfather that was trying to take care of her.  There was no medical background in the family and this situation with my grandmother was not being handled well.  Some blamed my grandmother – they felt that she was “faking”.  Others blamed her pain medications (to the point that they essentially took all of them from her).  Everyone started to fight, cry, and many stopped visiting or communicating.  My grandfather on multiple nights took my grandmother to our local hospital because he did not know what to do with her.  The last night that he took her she was septic and transferred back to the original surgeon who did her surgery.  She was found to an abscess at the level of her new spinal hardware so AGAIN had to go back to surgery.  On one hand, everyone was relieved that maybe the infection was the problem all along and she would now to cured!! On the other hand, here she was going through ANOTHER surgery.  Following the surgery my grandmother’s memory did improve some, but she is certainly nowhere close to the person she was before this all started.  The more I talked with my mother about this case; there were subtle things that had been missed – like the fact that my grandmother had been forgetting places and names long before her initial surgery.  She likely did have some mild cognitive impairment that certainly did not help her in the recovery phase – especially with delirium (and superimposed infection).  My grandmother knows our family members now and is functioning quite well at home, but constantly has to be monitored and requires quite a bit of assistance. 

This story is just one example of the impact that cognitive impairment can have on someone and their family.  It is important to accept the process of aging and understand cognitive decline.  My family has learned a lot this year thanks to my grandmother, and finally has taken the initiative to start learning about cognitive impairment and dementia and how to prepare as things continue to change throughout both of my grandparent’s lives.  Educating family members and patients about what to expect is clearly important in the case above, and something that I have noticed to be emphasized often during my month on geriatrics.  

 -- Lindsey Prochaska

Tweaking the discharge process

During my inpatient months I had not thought much about where the patients end up after their stay.  I know many are going to SNFs and rehabs, but I mostly just imagined a hospital-like setting with a focus on rehab and PT instead of on medical issues.  However, during my first week of geriatrics I realized how vastly wrong my ideas had been.  The care of patients in SNFs seems to be a cross between a hospitalist and a PCP.  You get to see the patients several times, in their normal clothes I might add, over the course of several weeks and are able to build a relationship with them and see (most) improve and able to return home.  You also realize all the things that fall through the cracks on discharge.  The person has diarrhea? It's good to know they don't have C.diff, but it might also be helpful stopping that BID sennakot-s.  Oh, yea lets remove that rectal tube at some point as well.  They were taking Benalopril prior to admit, lets change them to lisinopril b/c it's formulary on discharge.  They are confused, but we don't know what the baseline is, so we cannot justify hospitalization, so lets get them someplace where someone can keep watching them instead of dc'ing home, it's in the best interest of the patient after all.  All of these issues, and so many more, seem kind of oxy-moron after discharge, but while you are getting paged every 5 minutes you lose focus on the fine-tuning.  Being responsible for the discharged patient made me so much more aware of my discharging process, and I wish I had had that experience from the beginning of my residency. 

 -- Kellie Wark

A change in perspective...

I’ve spent years in clinic putting patients on medications to lower cholesterol, lower blood pressure, and improve blood sugars in hopes of extending their life.  I’ve pushed for dozens of colonoscopies, mammograms, and stress tests in hopes to prevent disasters. 

Now, I’m in Geriatrics Clinic taking people off medications and forgoing screening because, well, it’ll probably be something else that kills them first.

I’ve spent the other part of my three years on the General Medicine inpatient teams and ICUs trying to cheat death, halt death, or revive persons from near death. 

Now I’m in a Geriatrics Clinic and it feels like I’m actively planning for someone to die.

…But before you think I’m morbid, let me explain

It all started on my first day in Geriatrics Clinic when I was shown a chart of life expectancies for elderly persons in America.  The concept was simple enough, using a person’s age, gender, and overall health to determine how long they were likely to live.  It took more than an instant to digest that even a rather healthy woman  in her 70s may only have less than 10 years to live on average.  It made me afraid to be in my 70s.

With this information, however, came a new sense of purpose and a new outlook on what I was doing in this clinic.  It was easy to feel as if we weren’t “being aggressive” enough or that we were “being passive” but what it really showed was how at all ages in Medicine, the focus always remains on the patient.  With every decision I’ve made for every patient, every day in the past several years, the common focus is doing the best to provide benefit with the lowest possible risk.  While it initially seemed different than what I had been doing on before, it was the exact same.

So as we sat there, taking medications off her list which were unlikely to provide her any further benefit, it felt liberating.  It was not as I felt earlier, a sign of defeat, but rather a celebration of a life lived to its best.  And as we continued to talk, it was just like my usual clinic, continuing with every visit to make sure that everything we are doing is focused on living a longer and better life.  

What a Wonderful World

“And I think to myself, what a wonderful world”, sang the volunteer to the group of elderly individuals encircling her.  As she continued to sing to the group, I found myself, pen resting on the table, listening and reflecting on the aging population around her.  I was on my second nursing home visit and the geriatrics rotation had taught me two great lessons, the elderly population is complex and the goals of treatment are often different.

Medicine’s complexity has always interested me, the chance to investigate someone’s history, their multitude of symptoms, analyze the collected laboratory data, and formulate a plan. The geriatric population amplifies this process due to their atypical presentations and innumerable psychosocial factors, all in the face of a population with differing goals of care.

As a patient ages, the recommendations for screening and treatment change. The evidence based medicine I have so devotedly learned has been broken on this rotation. Each patient requires an individualized plan based on their physical illness, psychosocial components, and their personal goals. For example, is it truly beneficial to pursue colorectal screening in a patient with a terminal illness? More than once, I have had the opportunity to expand my medical thought process.

This rotation not only taught me to enjoy another multifaceted aspect of medicine, but also provided me with a renewed perspective on life; what are the most significant aspects of life and how to define quality of life.  Watching the volunteer move throughout the crowd, I caught a glimpse of what my future might be like and reflected on what is most important. What a wonderful world it is indeed.

 -- Leanard Riley

Dementia, the bigger picture

My experience in geriatrics has enlightened me on multiple levels. I came to realize the importance of looking at the bigger picture with older patients. It’s not just about focusing on medical problems but also aspects of daily living that may impact overall health. I discovered I can get to know someone very quickly simply by asking questions pertaining to ADLs and IADLs. These are items we as residents often overlook while training in the inpatient setting as we focus quite a bit on the acute problem. I also came to recognize the huge impact dementia has on a patient and their family. In my eye, it is a medical condition that doesn't get enough credit as it truly should. From a physician’s perspective, I realized I should pay more attention to this disease process as it has a multifaceted impact on a patient. In my opinion, unless a person has a family member or friend with dementia, the general public otherwise views this condition as ‘something old people get.’ I hope to educate people that it is much more than that. To look at this from a broader perspective, actor Seth Rogen recently presented a statement to members of congress to encourage funding for research into Alzheimer’s dementia. Despite his witty yet moving speech about his personal experience with a family member suffering from the disease, his presentation was made to a poor showing of congressmen. I have had the opportunity to see various types of dementia in person. I would hope that as time goes on that this condition receives more recognition to the general public's eye about its impact on overall health and ultimately lead to early recognition and appropriate management. Looking back now that I have come to the end of my experience with geriatrics, I do wish I could have had this experience during my intern year. I feel like it would have changed my practice with older patients. Nevertheless, I will definitely carry over what I have learned to the rest of my residency and into my career.

- Arvind Satyanarayan

Ode to the Caregivers, the unsung heros

I was ashamed. After I had been whining about a page last night disrupting my sleep, I met a most amazing woman. I made a house call to see a bedbound lady this morning, Mrs. D. She has been essentially non-responsive with end stage dementia for almost 4 years. And her daughter-in-law, Denise, has been caring for her at home as they say, 24-7. Because Mrs. D is completely paralyzed, she is at high risk of developing bed sores. But for 4 years in Denise’s care, she has not had one bed sore. This could ONLY be achieved because every 2 hours day and night Denise turns Mrs. D, changes her diaper and massages her skin. EVERY 2 hours for the last 4 years. That is 17, 480 times! (Ok, maybe her husband and teenage kids have helped a few times a week, so maybe she has only done it 16,000 times.) That’s just one of the many acts of caregiving she fulfills!

The dedication to perform the physically exhausting and repetitive tasks involved in this level of caregiving is clearly the outward expression of an incredibly deep love and compassion. Denise’s husband is thankful but she doesn’t get any thanks or any response really from the patient or the patient’s other children. Don’t all of us deep down dream about being loved that unconditionally?  WOW!

The crazy thing is, there are hundreds and thousands of caregivers like Denise. They are invisible to most of the world as they are confined to their homes full time or working in institutions like nursing homes that most people try to avoid at all costs. Just as you might not think about the components of your car that keep it functioning, you likely don’t recognize the importance of these caregivers—they may not be very visible but they really are the cogs in the engine of love and life. 

Inspiration from Old Hippocrates

"Cure sometimes, treat often, care always."

I've seen this quote attributed to the Father of Medicine and to Dr. Edward Trudeau (1800s), but I suppose it doesn't matter who said it.  

What matters is that it is a poignant reminder that despite medical advances over years, decades, centuries . . . our calling as physicians remains the same.

There are still so few diseases that we cure.  Perhaps we prescribe antibiotics that get our patients over infections, but much of our time is devoted to corralling chronic diseases, some more successfully than others.

When it comes to geriatrics, in particular, our patients face many conditions that march along becoming more debilitating over time - dementia, heart failure, Parkinson's disease, to name a few. 
Sometimes it makes one feel powerless when patients come to us seeking to "get better."  However, that's when I remember the last two words of the phrase.  Comfort always.  When we put science aside and relate to our patients on a human level, we are always doing them a service.  And perhaps we're doing ourselves as service, as well.