Many of our posts are culled from experiences with family, friends, and patients. All have been edited and modified so that they present general examples of the points we want to make rather than relate the story of any individual.
Pistachio Nuts: A new treatment for depression in the frail elderly.
“So what are you doing for fun?” I’ve been asking this question to my frail elderly patients lately. I still ask about falls, appetite, sleep, incontinence and their children. I make sure they’ve signed a health care proxy and been appropriately vaccinated. It’s all the right thing to do and many patients even appreciate how our office computer reminds me to check on these things but it doesn’t’ make them happy. She looked up from her lap blushed and smiled.
“Wow.” I thought. “This is good.”
“Are you confessing to having some fun?” We had talked about her non-doctor related life many times and this was not our first foray into the subject of fun but it was the first time she had something to tell me.
She is a large woman for 80. Just a tad under six feet. Her cane is as long as many of my other frail elderly patients. She’s got a pachyderm’s lumbering gait. She moves steadily if slowly. I offer my hand as she approaches the exam table but she reminds me, “Remember, doctor, I’m tall. It’s easier if I do it myself.” Truth is, if she really needed help, so would I. My colleagues and consultants have told me I’m wasting time by not having the patients already on the exam table when I come in the room but it helps me to see how they move. I’ve always had trouble remembering the details of the marvelous geriatric performance tests but my “watching them walk in the room and get on the table test” has probably saved a few broken hips.
“You’re moving pretty well today.”
“Thank you.” She’s a very quiet soft spoken person. She’s had a horrible ten years. Her husband of fifty years died suddenly a few years years ago. They were never able to have children and she is not very close to her nieces and nephews. She always has been quite active until she developed breast cancer five years ago and is being treated at our local cancer specialty hospital. She’s got hypothyroidism and hypertension. She used to love going to theater, book clubs and synagogue but over the past two years has just felt “too weak.”
“I’m just tired all the time.” She needs a two hour nap every afternoon. “And it’s a deep sleep.”
“So what’s the smile and blushing all about?”
“Remember how last time we talked about expanding my diet?”
“Right, you said you really liked…”
“Unsalted pistachio nuts.”
“Turns out I also like unsalted cashews.”
“This is good.”
I loved seeing the color come up in her cheeks. Her smile had turned from forced to impish.
“I hope it won’t be too bad for my diverticulosis, doctor.”
“It will be good for everything, especially your spirit.”
For the past two years, medical students in their third year of study (out of four) spend a month in our primary care medical practice. We have been told by the medical school that the students have reported that they really enjoy the experience. One of my partners and I do most of the work with the students and love having them spend time with us. The quality of the students has been outstanding. These are very bright, curious, and compassionate people who will not only take care of us when we are sick but will also help us learn to stay healthy. Toward the end of each rotation we ask the students what was the most important lesson they learned from the rotation. Often the answer relates back to a particularly interesting medical problem or to the varying style of practice between the doctors in the practice. This last rotation both students made an interesting observation: “It’s really important to have people in your life.”
Our practice, especially as I am a geriatrician, has a large number of very elderly patients. Many are becoming more and more dependent on others for a variety of self care issues such as physical care needs, attending to finance, and decision making concerns. And above those basic issues is the need for emotional support and just the “regular,” love and affection that helps make the good days better and the bad days easier.
This revelation lead to a discussion of how often we fail to treasure our most important relationships: from whom we choose to spend time with, to how we care for those we have been given or chosen including parents, children, siblings, friends, partners whether personal or professional. We do not chose our parents or siblings but I’m sure we could all do a better job with what we have been given. We’ve been told that even a small amount of daily exercise is important for good health but so many of us do not seem to have even 30 minutes a day for a brisk walk. Making time for those most important to us seems to be getting harder and harder. Work starts early and ends late for many of us. Is our commitment to others something we’ve designed or just let happen? When we walk into our doctor’s office for a check-up when we are eighty years old , what will the medical students hear when we are asked “Is there anyone we can call?” Will we smile and give the name of one or two persons who are valued and loved or will there be a whispered, “not really.”
Cherishing our relationships takes time, effort, and practice. Yes, practice. Being with people is a start but then go a step farther by offering praise for a valued accomplishment or thanks for that regular “just to talk” phone call or a word or gesture of affection. Do not let hard feelings fester. Get them out in the open and let them heal, and whenever possible, forgive.
As usual this observation by our students was unexpected and powerful. It is something they will bring to their own lives and the lives of their patients. I feel grateful to teach and learn from these young people. I cherish their presence in our practice.
Not Enough Good Advice
I’m having a very busy afternoon in the office when my assistant pages me. “Dr. Brody, pick up line four it’s the emergency room.”
I apologize to the patient sitting next to me and pick up the phone. “Dr. Brody, this is Dr. Jones, your patient Mrs. Ralston, eighty year old woman with no significant past problems, came in a couple of hours ago. Her neighbor came with her. Seems as though they heard a loud thud coming from her apartment and called the super. Found her on the floor with a good crack in the head. We had to put in about twenty stitches. We did a brain CAT scan and no problem. She’s up now, walking okay, ate a little something and wants to go home.”
So no big deal, right. An old person falls and injures herself, happens every day. Could it have been prevented?
Flash back about two years. Ms. Ralston comes in for her first visit. Her doctor of 33 years retired and she heard that I specialized in geriatrics. Her daughter found me on-line, plus my office is close to her apartment. She never really wanted much medical care. At age 63 her doctor said she should be on cholesterol lowering medicine, a baby aspirin and one pill for her blood pressure. She said she’d watch her diet and let him recheck her pressure once in a while. The only thing she did agree to was a sleeping pill because she found it was getting harder to fall asleep.
“He made me go for this test to be sure I didn’t stop breathing at night before he would give me a sleeping pill so I went.”
The sleep study was normal. No sign of sleep apnea and the doctor prescribed zolpidem(Generic for Ambien) at the lower dose of 5 milligrams. About ten years later she said that the 5 milligrams no longer worked so at about age 75 the dose was increased to 10 milligrams. This was her only medicine when I saw her for the first time about two years before she fell. I explained to Mrs. Ralston and her daughter that the side effects of zolpidem increased as she was getting older and advised she cut back and try to stop the medicine. About six months before she fell, she came in for a check up with a broad smile.
“I stopped those damn sleeping pills and I think I’m thinking better.” Her daughter who almost always came with her, agreed. “I just read myself to sleep. When I get up to pee, I read a little more.”
So why did she fall? Did it just happen? About ten days later , when I saw her to remove the sutures, I found out.
“Can you think of why this might have happened, Mrs. Ralston?” Her daughter did not give her a chance to answer.
“It was the zolpidem, Dr. Brody.”
“I thought she had stopped that.”
She had stopped it but about two weeks before the fall, her grandson was involved in a motor vehicle accident. He suffered serious injuries but was recovering nicely. She told me that since the accident she was not able to fall asleep
“I just keep thinking about, Roger.” She had five of the 10 milligram ambient left so she took one and the following morning, she fell in the bathroom and hit her head.
1. Advising elderly patients to take as little sleeping medication or other sedatives as possible is still good advise.
2. Finding out what medicines a senior has in her medicine cabinet can help prevent medication errors by the doctor, patient and family.(I always ask my patients to try to remember to bring in all the bottles and am frequently surprised by what I find. Family and caregivers are also surprised by what they find.)
3. Restarted sleeping pills and other mood altering medicines(eg Tranquilizers) after being off of them for a prolonged period of time(eg Months or even just several weeks) may cause serious harm, as it did for Mrs. Ralston. Her mind was no longer accustomed to the zolpidem and also no longer metabolized it as quickly. She was more sensitive to its affects on balance and, because she now metabolized more slowly, developed a higher level that took longer to decline.
Mrs. Ralston had done right by herself for getting off the sleeping medicine. Would warning her about restarting the medicine have prevented this accident? It may not have but this has now become part of my advice when talking to patients about sedatives and tranquilizers. I had given her good advice just not enough good advice.
We’re back. We’ve been away for a month: new granddaughter, vacations, visits with close friends who live far away. All good and important things. Also we got almost 2000 spam comments which we needed to learn how to deal with. all good. so please keep reading.
Don’t Get Old
It was a beautiful sunny warm, but not too warm, summer day. I was on vacation. Quite a combination. Spending a week at one my favorite places in the world, the Chautauqua Institution. May not sound like the kind of a place for a geriatrician and a psychiatric nurse to spend a week of precious time off, but there is no better place. I have something rare at Chautauqua, a few hours without anything I want to do. Notice I said, “want to do.” There’s always something to do. So I’m walking back to our apartment when I see a young gentleman rush to the steps of one of the many homes on the grounds. There is a woman lying on the steps. I also quickly move to the steps where the young man is already helping an older person up from the ground. (Although the person on the ground is not my patient so privacy is really not an issue, I have changed some of the facts out of respect for the person we helped.) The woman has what I interpret as a bewildered look on her face. I’m thinking she might be confused or dazed. Perhaps she hit her head but here is no blood on the ground and with just a little help from the young man and myself, she’s quickly on her feet. There’s a quiet moment. Actors might call it a beat and it was a dramatic moment. Unfortunately for the older woman this was no act.
“Don’t get old, damn it.”
“Does anything hurt?” I asked.
“Damn it. Damn damn!” She held on to us as she continued to express her displeasure. The geriatric physician in me wanted to go right into action but the young man’s next words started edging me back into vacation mode.
“I think she’s okay.” No question mark. He had done his assessment and, I thought, was probably correct. I allowed a quick beat to occur before I decided what to do next.
“Let us help you up the steps and then you can sit down.”
She did not need much help. Probably did not need any but we each kept close. She moved slowly but steadily and finally reached the chairs on the porch. She stood by the chairs looking out into the small garden she had been working on.
“Make sure not to get old.” She said turning her gaze from the garden to the two of us. I have trained myself not to offer overly optimistic statements in this situation but the temptation was more powerful than when I am in my office. My semi-civilian/vacation status had lowered some of my well established patterns. Still I decided to say something about the statement.
“We all do…unless”
“Right, right. Still it stinks.” She said with something between a smirk and scowl on her face.
We talked for a bit longer. She was there by herself. She had come for years with her husband who had died a few years earlier. She said she had tripped while trimming the hedges. She had not hit her head but thought she might have scraped her elbow. She had.
“Would you like me to call someone for you?”
“My son lives in Cleveland. I’ll call him later.”
The young man was a voice student and said he was going off to a rehearsal. I decided not to identify myself as a doctor who like all of us is getting older.
Patients regularly repeat the words of the woman we helped up. “Don’t get old.” What does it mean? I guess it is different for everyone. What does it mean to be young? Young people fall. Young people get confused. In many ways the young are even more confused about life than us seniors. Difference is, most of the time, young people have years to figure it out and are usually able to get themselves back on their feet. We, sometimes, need help getting up but then we’re up. That’s the point. Keep getting up. Keep moving. Get help when you need it. Use a cane or walker because it helps keep you vertical. Get a scooter if you can no longer walk far enough to get where you want to go but, as long as you can, get there. Write yourself a note if it helps you remember where you want to go or what you want to do. There’s not cheating. Just keep getting old.
Awaiting A Birth
In our book and on this blog we spend a lot of time discussing end of life issues. The goal is to make one’s last days as meaningful and comfortable as possible. We try to include other topics because health care and the elderly is not just about end of life issues and, frankly, it would become depressing if that is all we talked about.
Today we are awaiting the birth of our third grandchild–our first granddaughter. One of the blessings of living to an older age is to see the next generations born and grow. As a friend of ours said, “A grandparent has a great job description.” The usual understanding is that you can enjoy your grandkids and then give them back to their parents when they get cranky or you get tired.
However, we have older adult friends who provide all or the bulk of the child care for their grandchildren and in some cases great-grandchildren. Some do this for financial reasons; others for convenience; all out of love.
Being close to grandchildren is wonderful and helps keep us mentally and emotionally younger but we need to be sure to pace ourselves physically. Young children can be exhausting and lifting them up and pushing them around can cause trauma to our older muscular-skeletal system. Just as with care-giving to an elderly spouse, knowing our limits and when to ask for help is necessary for us to stay fit and do as much as we can.
The circle of life continues. Can’t wait to hold this little girl in our arms.
As a doctor, I frequently have to give a person bad news. Each experience is unique but there are many themes that emerge. One of the most difficult, for me at least, is when the family asks me not to tell the patient. The following story is completely fictional but emerges from the many experiences I have had.
Morton Bliss fainted during this 90th birthday party in the grand ballroom of the Lucent Plaza in midtown Manhattan. The restaurant near his home would not have been large enough for the 632 guests. Morton had lived in that home with his wife of 62 years. Margaret died suddenly five years earlier. Morton found her in the kitchen of their home when he returned from work. He was the founding partner of a large accounting firm and with the help of a few younger associates, he continued to manage a dozen clients. He also consulted on new clients when one of the partners wanted his input. He had told them, “You kick me out of here if I’m not holding up my end.” His body was becoming weak. He needed a walker, had lost some weight, and liked to take nap after lunch. But his mind was sharp and his judgment was excellent. He had smoked from the time he was sixteen until his fifty-third birthday when his daughter asked him to stop in honor of the birth of his first grandchild. “I’ll do it.” And he did.
Michael Gord, Morton’s first grandchild, was the apple of his grandfather’s eye. Like his grandfather, Michael was brilliant and ambitious. “But I’m not too proud to join the firm, Grandpa.” Under Michael’s leadership, the firm grew to more than 250 employees with offices in New York, Chicago, Los Angeles and London.
“I know you hate surprise parties, Grandpa, so I’m telling you we’re having a party for your 90th.” Morton, agreed without argument, under the condition that everyone in the firm, plus a guest or two, be offered the opportunity to attend.
When he fainted Michael was at right there and called 911 from his cell phone but Morton was quickly awake. “I had a little to much to eat and drink. Just get me up and I’ll be fine.” Michael rode in the ambulance with his grandfather and remained with him throughout the night. The blood tests, x-rays and scans seemed to never end but at 5:30AM, the young doctor tapped Michael on the shoulder and said she’d like to talk to him. Morton was sound asleep.
“Well, Mr. Gord, there’s really nothing to explain why Morton fainted. As he told me when you first arrived it was probably just too much food and drink. We don’t have all the final results back but he is cleared to go home. Just be sure he’s not alone for a few days to be sure he’s back on his feet.” She also told Michael to schedule a follow up with Morton’s regular doctor who would get all the final results when they came in.
Michael called me the same day.“Dr. Brody, I don’t know if they’ve already called you but Grandpa was in the emergency room yesterday.”
“What happened, Michael.”
“He’s fine actually. He fainted just as we were about to take him home and I insisted he go to the emergency room. The doctor said he probably just had a bit too much to drink, eat and the excitement but they want you to see him. They also said you would get the final test results and I’ll decide what to tell him.”
“I’ll look for them and we’ll get him in a day or so if that’s okay with the two of you?”
“That’s fine, doctor Brody, but there’s one thing. In case there’s any bad news, I just as soon you’d tell me first.”
Morton had recently changed his health proxy and Michael was his new health care agent but Morton still had full capacity to make his own decisions. I just hoped there would be nothing I’d have to tell him.
When the final results came in two days later the brain CAT scan showed a small, probably benign brain tumor in the front part of Morton’s brain. This finding, very likely, had nothing to do with Morton’s fainting and would also have very little chance of changing how long or well Morton would live.
Who do I tell first? I’ll need both Michael and Morton to trust me as we move forward with Morton’s care over the next several years. Both men are very strong minded and used to getting what they want. Yet I’ve know them for years and both are usually reasonable when they are given full disclosure as well as my opinion about how to handle a problem. When Morton was 84, he had what turned out to be his first and only, gallbladder attack. Neither Morton or Michael were eager for surgery but Morton was in good shape, my surgical colleague said that since Morton had never had previous surgery she’d be able to remove the gallbladder without difficulty. I knew that if Morton had another attack it could be far more stressful than removing the gallbladder when things were stable. Presented in this manner, and after a few days to talk, Morton elected to have the surgery and fortunately all went well.
“Michael, this is Dr. Brody.”
“I guess you got the final results?
“I did, Michael…”
“This does not sound good.”
“Morton has a small brain tumor in the front part of the brain called the fontal lobe. It probably has nothing to do with the fainting spell and is unlikely to cause trouble at least for many years so given Morton’s age I think he’s going to do fine.”
“I do not want you to tell him, Dr. Brody.”
Here are the reasons patients’ families and loved ones provide when asking me not to tell:
1. It will just upset them. He will not be able to take the news.
2. Since you do not think it will change anything why bother?
3. He’s doing so well won’t this just ruin the rest of his life?
The following are some of my thoughts when trying to convince the Michaels why the Mortons need to know:
1. He’s got full capacity and has a right to know. (This is probably enough for me to override Michael’s objection.)
2. He would want to know.
3. Ask Michael how he would feel if the circumstances were reversed.
4. Discuss with Michael how I plan to inform Morton and, if Michael would like, have him there when I talk to Morton.
5. Explain that despite my experience and the strong reading of a benign tumor by the radiologist, I still feel Morton should get the opinion of an experienced neurologist. Sometimes even small tumors can cause complications and Morton, his family, and doctors should put themselves in the best possible position to handle such contingencies.
I’m sure you can think of other reasons on either side of the argument. It has been my experience that it is very often more the family member and loved one who is having trouble dealing with the situation. They wonder how they will cope with the patient’s reaction. Will they be able to deal with the fallout? Do they want to? Perhaps they have had previous experiences with their loved one and feel they have “good reason,” not to tell. When I am confident that my patient has capacity I will do everything I can to convey the information to the patient. I am usually able to get loved ones to agree that telling is best. In the end, a person with the intellectual and emotional capability to understand his/her situation must be told.
When Michael continued to hold strong I asked him to come in to speak to me face to face. We each reviewed our positions. I ended by explaining to Michael that unless he had some reason to feel his grandfather was too emotionally unstable to handle the news, his grandfather must be told. We both knew that Morton had more than enough intellectual capacity to understand the situation. Perhaps Michael knew something about Morton’s emotional state, which heretofore, including the death of his wife, had been rock solid.
“No, Dr. Brody, Grandpa’s a tough guy.”
“Then let’s tell him what he has.”
Morton was told, coped well, and is back at work. The neurologist agreed that the tumor was unlikely to cause a problem and asked that the scan be repeated in six months just to see if it were changing in size.
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Sam & I were walking yesterday and for some reason we tried to calculate how many miles we have walked together as exercise. We started doing 3 miles almost every day about 25+ years ago. In fact when I was in the elevator on a stretcher being wheeled for surgery, the man in the next stretcher (also going to surgery) looked at us and said, “I know you. You are the walkers.” At first we thought he meant that was our name but he explained he had seen us walking in the neighborhood many times and that we had inspired him and now he was a walker too.
We do not walk 21 miles a week together. Sometimes our work schedules conflict. Sometimes the weather does not cooperate. But we walk in very cold temperatures bundled up, and in light rain, and in the dark during the short days of winter. We figured we have walked about 20,000 miles together–almost enough to circle the globe–4/5 of it anyway.
I bring this up not to brag but to reinforce the old saying, “A journey of a thousand miles begins with the first step.” That first step is so important. Also keeping the focus on what can be done today–not some lofty far away goal. Too often we hear people say they have no time to exercise, no motivation (you get the same health beneftis walking whether you are doing it with or without motivation),and no energy. Small and consistent is better than the occasional overexertion. As we age, developing good health habits and making healthy lifestyle choices is still critical. Long term health problems will respond to even little changes in what we do.
Since the beginning of the year I have been working to become a vegetarian. I am doing this for several reasons including 1. my rising cholesterol and inability to tolerate the anti-lipid medications 2. ecological concerns 3. ethical/humane concerns. It was fairly easy to eliminate the mammals as Sam is not much of a meat eater also. Learning to do more with tofu and hummus helped. I have cut way back on my poultry consumption and find it less difficult to resist. Seafood will be the last to go if I make it there. But I have many–almost a majority -of days vegetarian and it is easier as time passes. This is crucial. Give yourself a chance to get to the point where these types of behaviors are easier. Not easy but easier. A few days or even weeks is not enough but you will get there.
I bring this up because many people say if I cannot be 100% this or do 100% that than I do not want to do it at all. This all or nothing approach leaves many with a lot of nothing rather than a little something that can be nurtured and grow. Again, even small positive changes can have big payoffs health-wise.
Now back to the walking. Beyond the physical health benefits of all those miles, the joy of seeing the changes in the seasons, the people in our neighborhood, and our mostly uninterrupted time to talk has enriched our lives. Its hard to believe we have walked almost around the world right here in our town. But we continue to enjoy the journey.