Friday, July 24, 2009

Elder Care and the Whole Patient

An elderly person with no specific deadly illness like cancer, is still likely to suffer from many of the standard ravages of old age: high blood pressure, cholesterol issues, weak bones, perhaps some anxiety about it all. To treat these health issues that one person will see a cardiologist, orthopedist, psychiatrist, endocrinologist, neurologist and more. Each will prescribe tests, procedures, treatments, medications. Who coordinates it all? Who's looking out to make sure that the new drug prescribed by the neurologist for back pain, doesn't conflict with, or diminish the efficacy of ,a drug prescribed by the cardiologist? The answer, usually, is: No one.

This is one of the most serious matters confronting care givers, care managers and, of course, the elderly person themselves. Unfortunately, though our medical system puts us in the position of needing to monitor medications and our elder loved ones' physical and mental well-being, we are often not the most competent to do so.

Purely on the physical side, it is known that, when you get to your 80s and 90s, your body becomes exquisitely sensitive to drugs. For this reason, not only are lower doses sometimes used for the elderly, but their body doesn't clear the medications as swiftly and fully as does a young person's body. Thus, periodically, drug toxicity can develop in the elderly, simply because their system hasn't eliminated the daily dose of drugs as it should.

There are geriatric internists who strive to maintain a thorough list of their patient's specialists and the medications each prescribes. But they rarely have the support of those specialists. And without that support, which entails sharing of information after every visit, their hands are tied. It's not that doctors don't want to work together. It's rather that specialists in particular have a narrow field of vision about what they're treating. Simply by virtue of having selected a specialty, their tendency is to focus on that part of the patient's body exclusively, rather than viewing their patient as a whole.

A new approach to achieving this Holy Grail of being viewed and treated as a whole person, rather than as a heart or a spine, is being implemented at certain clinics and hospitals. It's called a "medical home." This is not the same as our current system of managed care, where the internist acts as gatekeeper, referring their patient to this or that specialist. In the medical home concept the internist is the head of a team, keeping track of treatments, making sure specialists know of a patient's progress and generally ensuring that treatment is seamless, no matter which physician a patient is seeing.

Now, take this concept and factor in the frailty, dementia, worries of old age. You can see immediately that this approach would be a godsend for the elderly. The model is not at all widespread yet, but it's still worth using this model when visiting with your parent's internist, to see whether they can provide some thing similar to it. I advise, though, that even those who are willing to attempt to keep track of what each specialist is proposing, will need your help. Since your parent's doctors will not consider themselves a team, you may find you'll have to do the legwork and phone work to make sure information from each specialist gets sent to your internist, to be added to your parent's general file.

This effort is hugely worthwhile, as I can personally attest. My experience is that, when doctors know that an elderly patient has an advocate who's tracking medications, and an internist who's interested in the overall well-being of your parent, they unconsciously pay more attention themselves. I have never encountered a doctor's assistant who wasn't willing to fax the information I requested to my mother's internist. And I've never encountered a physician who wasn't willing to take a few moments to explain to me their rational for changing a dosage or a drug.

So, get involved with your parent's physicians. Keep your own record of what drugs and dosages your parents use. Follow-up with the doctor's office after a visit and ask them to transmit their records to your parent's internist. These days this can be as simple as a short fax or email. If something significant changes with your parent's health, you'll be amazed at how helpful these small efforts will prove to be.


bonnie said...

Learned some things to tuck in my brain. I am clear across the country from our 90 yr. old mother who has dementia. She also has always had a very negative personality and pits one sibling against another. This is not helping in hers or our lives at this time.

She has a fine caretaker 4 days a week who is more adept dealing with her than I am.

Mom goes on pity parties all the time. She refuses to leave her home where she lives alone. I never know what to say to her to get her off topic.

It is extremely gut wrenching for all of us.

Dina said...

Hi Bonnie,
Your situation is a hard one, given your mother being quite old, living far away and having dementia. Somebody once told me a truism, which is, as we get older, our fundamental personality traits stand out and become more hardened. It sounds like that's the case with your mother. I imagine that, since her natural inclination is pessimism, the struggles with dementia must be especially depressing for her. And it can't be pleasant for you and your siblings to feel you are still being pitted against each other.

Still, a few things come to mind as I read your comment.
1. You're not likely to be able to change your mother. If possible, try to pull back, detach a bit, and keep your interaction with her to the objective necessities for awhile. IN other words, try to remove from her grasp those things which give her leverage over you and your siblings.
2. Be relieved that she has a great caretaker with whom she gets along. Let that caretaker be to your mother the things which she won't let you be. And recognize that, even though your mother may not or cannot express it, that caretaker won't replace you in your mother's heart.
3. Your mother may not be leaving home because she's now too uncertain or confused to do so. It is terrifying to be affected by dementia in this way. And the proud elderly are loath to admit they don't know where they are. It's possible your mother simply is scared to go out, and, if this is dementia related, she's right to be frightened.
4. A geriatric psychiatrist once told me that I was my mother's enabler. To the extent I gave her sympathy for her aches, pains, loneliness, etc., I fed her the reaction and engagement she was craving. In the weird world that is the human psyche, by satisfying her craving, I only made her try to make her symptoms she'd get more sympathy. He suggested I simply stop responding to her with sympathy. He advised instead that I coolly acknowledged her statement and move on to something else. If she insisted on dwelling on her problems, I was to tell her that I would be happy to spend more time on the phone with her, but not on that subject. It worked like a charm. Within a couple of months, her symptoms of distress diminished significantly, our conversations became truly more bilateral and pleasant, and she felt better overall.
5. Your email reminds me much of myself, in terms of my guilt and agony at my mother's lonely life. I don't want to sound tough or unfeeling when I suggest this, but you may have to realize that your mother has made her choices. Her life is what she has made it. There likely have been many things in her life that she found fulfilling, even if they didn't make sense to you. And like everyone, she's had her disappointments. AT 90, she is the way she is. Since you can't change her, change your reaction to her. THat's something you have within your grasp to do. First, give your mother the grace of acceptance (she is who she is). Then, when she runs her plays, laugh them off; the physical impact of actually laughing will make you feel better and derail your standard gut wrenched reaction to her. Then, immediately tell her you're saying good-bye now, and hang up. Don't let her engage you in repeat rounds of pulling your strings.

Hope some of this helps.