"Well, alright then. See you later I guess," says your patient's son, who is clearly not thrilled about your decision not to declare his father mentally incompetent. As he wheels him out of the office, his father, a 93-year old man you've known for years, gives you a wink. This reminds you how much you love your work, and that after all, it is the kind and frail elderly that are your priority - not their occasionally ungrateful family members.
You invite the next patient in. She is accompanied by her son. Mary is an 85-year-old woman who walks very slowly and seems unsure of her steps as she clings onto her son's arms for balance. "Hello Mary, hello Jeff, how have you been?" you greet them with a big smile on your face.
This is only the second time Mary has been to your office. Last week she came in with Jeff, complaining of recurrent falls over the last few months. She had been falling all over her apartment, which she shares with her cat. One night, she fell over in her bathroom in the middle of the night and had no one to help her get up. Jeff, worried for her safety, decided to have his mum stay with him and his family after that fall. Jeff also reported that Mary has trouble sleeping at night, that she wakes up during the night and reads her books, but naps during the afternoon. She also needs to pass urine frequently at night. You couldn't find anything else unusual in her history and found no abnormalities on the physical examination except multiple bruises of different ages, which were compatible with the injuries she's been sustaining on a regular basis. For completeness, you ordered several investigations that you are due to discuss today.
Mary has a 20-year history of diabetes, dyslipidemia, and arterial hypertension. She was a heavy drinker and a smoker since adolescence but quit both 15 years ago, after suffering an acute myocardial infarction. This was treated with thrombolytic therapy and followed by aggressive lifestyle change management. Mary currently receives a tablet per day of aspirin 75mg, furosemide 20mg, carvedilol 40mg and rosuvastatin 40mg. She also has metformin 850 mg with her morning and evening meals and takes paracetamol 500mg whenever her osteoarthritic pains worsen. Mary used to work as a teacher. She has been living alone since after she was widowed 10 years ago. She has two sons: James who is 60 years old, and Jeff, who is 55 years old. Both of them are healthy and well. It is Jeff who accompanied her today.
Mary has a body mass index of 24.3 kg/m2. Her heart rate is 85 bpm and completely regular. Her blood pressure is 120/60 mmHg lying down and 100/50 mmHg standing up. The general examination is normal, as are the cardiorespiratory, abdominal, and neurological examinations. She completes the mini-mental status examination with a near perfect score. You perform a diabetic foot examination but note no ulcers, infections or deformities. Her pressure, vibration and proprioception sensation is preserved. Her random blood sugar is 155 mg/dL. You decide to perform a "Timed Up and Go" test, and ask Mary to get up from her chair, walk ten feet, turn around, walk back to the chair, and sit down. She looks quite unsteady while doing so, and takes fifteen seconds to complete the task.
Regarding the lab workup you ordered last week, Mary's results are all normal, except for an HbA1c of 7.5% and FBS of 118 mg/dL. Her complete blood count, electrolyte levels, lipid profile, liver functions, kidney functions, thyroid function tests, and vitamin B12 levels are all normal. An ECG shows no abnormalities. The echocardiogram report notes an ejection fraction of 45%, with functional mitral regurgitation, mild dilation of the left ventricle with normokinesia, mild biatrial enlargement with normal left atrial pressures, and moderate apical systolic dysfunction. A carotid ultrasound is negative for carotid stenosis.
Given the lack of organic culprits, and the insistence of Mary and Jeff that her house is uncluttered with no problematic wires or furniture, it appears that Mary's medications are the reason for the falls. What will you do now?
Several weeks later, you arrive at work, only to discover a fat file on your desk. Shivers run down your spine when you read its contents. A case has been filed against you for medical negligence. The core of the claim is the improper treatment you provided Mary by "stopping her beta blocker abruptly." She experienced a heart attack just a few days later.
Two weeks later, Mary arrives at your office. You notice that her wrist is wrapped in an elastic bandage. She fell over a few days ago when getting up from bed, and sustained a nasty sprain. You realize that focusing on carvedilol was a mistake, and thank your lucky stars that Mary didn't sustain a fracture.
You explain to Mary that her falls are quite likely due to her blood pressure dropping at times. When considered along with the frequent episodes of urination during the night, a quite severe inconvenience, it makes sense to discontinue furosemide. In addition to cessation of furosemide you also suggest referral to a physiotherapist for assessment, further education and a physical therapy program to reduce her risk of falls.
Jeff asks: "do you think her diabetes drugs could also be a problem? Will you change them as well?" You recall that Mary's most recent FBS and HbA1c were 118 mg/dL and 7.5% respectively. What will you do?
You prescribe glipizide 5mg with Mary's morning meal along with her regular dose of metformin. A few weeks later Jeff brings Mary along for review of a head wound. One afternoon she was getting up from her armchair and felt dizzy. She fell over and knocked her head on the side table. At the hospital, they dressed the wound and told her the dizzy spell was due to a hypoglycemic attack. She was then taken off glipizide. You realize that you've learned a lesson about prescribing multiple anti-diabetic agents to an elderly person. Good thing Mary is all right now.
You prescribe pioglitazone 15 mg with Mary's morning meal along with her regular dose of metformin. A few weeks later Jeff brings Mary for continuing care after her discharge from the hospital. She had been hospitalized with progressively worsening shortness of breath and treated for acute heart failure. This was attributed to pioglitazone, which the hospital staff subsequently omitted. You realize that you've learned a lesson about prescribing multiple anti-diabetic agents to an elderly person. Good thing Mary is all right now.
You explain that Mary should continue with her regular metformin regimen, as her HbA1c is only slightly elevated. People of her age don't appear to benefit from intense hypoglycemic regimens, and may even experience unnecessary complications.
You decide to prescribe the benzodiazepine lorazepam. Shortly afterward, Jeff and Mary thank you and take their leave.
You decide to prescribe the non-benzodiazepine hypnotic zolpidem. Shortly afterward, Jeff and Mary thank you and take their leave.
Several weeks later, Jeff brings in Mary to see you. He angrily tells you that her insomnia hasn't improved and that she's also become irritable during the day. To make matters worse, she suffered a fall yesterday, again while getting up from bed. You realize prescribing sleeping pills was a bad idea.
"Let's focus on sleep hygiene then," you say, and continue, "the sleeping pills don't seem to be working, and are contributing to Mary's unsteadiness. They are probably why she's irritable during the day, as they can cause withdrawal symptoms once one gets used to them." Jeff's anger eases somewhat, and he nods in agreement. You realize that he feels guilty, as it was him who requested sleeping pills for his mother. Nonetheless, as a doctor, you really should have thought about the potential consequences.
"Let's focus on sleep hygiene first," you say, and explain, "I'd rather avoid sleeping pills. They can make you drowsy and unsteady, and cause even more falls." Your thorough explanation about the effects and dangers of these medications convinces Mary and her son to try out conservative measures first.
The consultation being over, Jeff and Mary thank you and take their leave.
Your next patient is a lovely 77-year-old lady named Inés. She tells you she hasn't seen a doctor for over a year and that she is in your office today just for a general check-up. She has no complaints apart from osteoarthritic pain in both knees, that she describes as worse in the evenings, and stiffness which appears sometimes "after running errands all day." The pain significantly limits her physical activities. Cleaning the house leaves her debilitated with pain in her knees for a few days, necessitating around-the-clock paracetamol tablets. On the review of systems, Inés doesn't report any other issues, apart from "feeling constipated at times." Her medical history is significant for chronic osteoarthritis of both knees, uncomplicated peptic ulcer disease 15 years ago, and seasonal hay-fever. The last x-rays of her knees were taken two years ago. They showed moderate degenerative osteoarthritic changes. She was screened for diabetes, hypertension, chronic kidney disease, and dyslipidemia last month, but all tests were negative.
Inés isn't on regular medications, but takes stool softeners and occasionally, over-the-counter analgesics for her painful knees. She has never smoked but takes a glass or two of red wine with dinner every now and then. She is the mother of 3 children, all of whom are alive and well. She had a hysterectomy 35 years ago for symptomatic fibroids. She doesn't exercise and tells you she prefers indoor activities. She admits that she could improve her diet, which in her opinion is most probably causing constipation. Her mother and father had long and healthy lives. Her two older siblings live in Nicaragua and are both alive and well. She worked for many years as a waitress in a restaurant until she finally retired at the age of 66 as a manager. Her husband died 5 years ago, at the age of 80.
On examination, Inés's BMI is 22 kg/m2. Her gait is normal even though you reveal some limitation of range of motion in both knees. No other signs are present. While speaking to her, it is clear she is mentally intact. You might even say that she is as sharp as a needle.
You perform several routine office investigations. While doing so, you note that urinary dipstick testing is positive for microhematuria and nitrites. However, Inés denies the presence of urinary symptoms such as dysuria, urgency, incontinence, frequency, or nocturia. What will you do now?
You inform Inés that she has a urinary tract infection (UTI) and that you're considering starting antibiotics. However, the sharp old lady retorts: "I'm confused, doctor. Do I really need antibiotics when I feel just fine?" You realize that she is correct, and tell her you'll be sending her urine sample for further analysis. You schedule her next appointment to when the results will be available.
You inform Inés that you are happy with her health assessment and you praise her for deciding to come for a routine check-up anyway. You also tell her you'll be sending her urine sample for further analysis, and schedule her next appointment to when the results will be available.
Several days later, Ines is in your office to discuss her results. There's been no change in her physical or mental well-being in the meantime. Urine culture reports are positive for E. coli with a quantitative count of 105,000 CFU/mL. You are glad you didn't prescribe antibiotics, and inform Inés that she has asymptomatic bacteriuria which doesn't need treatment. You also explain the symptoms of a UTI and how to prevent them.
Inés thanks you. She then informs you that her knee pain just keeps on getting worse and that paracetamol doesn't seem to help at times. She asks if you could prescribe something for this. What will you suggest?
You advise paracetamol up to 3g/day and schedule a review. Several weeks later, Inés comes to your office, this time using a walking stick. She tells you that no dose of paracetamol seems to be helping her knee pain and she can't seem to cope with it anymore. You realize that making her suffer through acute flares of pain is both cruel and unnecessary, and consider other analgesics.
You prescribe codeine 60mg PRN to help with the pain. Inés comes back to your office just a week later. While she is completely pain-free now, she has recurrent abdominal cramps and is severely constipated. You realize that her symptoms are a direct result of opioids you prescribed, and decide to change her analgesic therapy.
You estimate Inés to be at moderately increased risk for NSAID GI toxicity, and therefore prescribe diclofenac sodium 150 mg/day for flare-ups, with 40mg esomeprazole for gastroprotection. This course of action both spares her from the pain while also mitigating the risk of complications from the therapy.
You also give Inés extensive advice on the non-pharmacological treatment of osteoarthritis in people of her age and recommend knee bracing, adequate footwear, physiotherapy, and exercise. She is extremely happy with your explanation and caring approach. "It took me a while, but I am so happy to have finally found a doctor who knows how to treat my concern, rather than my disease." she says. Inés thanks you again for your help and leaves your office.
The next morning, you are about to start your rounds in the geriatrics ward of the university hospital where you work as a visiting specialist. Two final year medical students are supposed to be shadowing you today. You meet them at the nurse's station. They appear tense and very serious about their work. They have been on the ward since early this morning, examining patients and reviewing their charts. You introduce yourself, get their names and head out to meet Francis, a 95-year-old World War II veteran with Alzheimer's disease who was hospitalized due to a bronchopneumonia 10 days ago. You greet Francis and ask him how he is feeling today, but all you can tell from his monosyllabic answer is an acknowledgment for engaging him. You can't understand anything from his attempt to talk. He seems very weak.
One of the students starts presenting the case. You learn that Francis is a resident in a nursing home and that he has a history of chronic heart failure. He is completely dependent on assistance for basic activities of daily life, including feeding himself. The nurse's notes reveal concerns about a swallowing difficulty, more for fluids than solids, that he has been experiencing since the last couple of days. You examine his oral cavity to assess if loss of teeth may be causing this difficulty; and also to exclude local causes such as oral moniliasis. A pressure ulcer was discovered this morning on the prominence of the right ischial tuberosity. It is bright red in color and looks like a shallow crater, measuring about 6 cm in diameter and with a 1 cm depth. The surrounding skin looks healthy, there are no purulent secretions or evidence of necrosis. You begin to examine Francis and give step by step explanations to the students, making special mention of the classic stigmata of heart failure that are clearly present.
The second student doesn't seem to like your answer. Just as you didn't think he couldn't look any more serious, he furrows his eyebrows and interjects: "Doctor? Isn't this a stage 2 ulcer? There is partial thickness skin loss, with no necrotic tissue. It's superficial, like a shallow crater, and most probably involves only the epidermis and dermis." Being corrected by a mere medical student isn't quite how you imagined the day to start. Nonetheless, you realize that he is correct.
You explain that this is a stage 2 ulcer because of the partial thickness skin loss, with no necrotic tissue. Given the "shallow crater" appearance, it most probably involves the epidermis and dermis only.
You ask the second student to describe the treatment, which he appears more than happy to do. He mentions continued assessment for changes, periodical repositioning, support surfaces for pressure distribution, wound cleansing and dressing. His information is flawless and you commend his answer.
The student looks confused. "Uh, debridement has been planned given the absence of necrotic tissue?"
The student looks confused. "Uh, no antibiotics were prescribed, as there is no evidence of active infection of the ulcer?"
You are mortified by your mistake and stammer out: "Ah, I'm sorry! I meant that proper nutrition is vital. This morning the nutritionist was consulted and Francis is currently on his proper daily caloric and protein needs, and his vitamin requirements."
You obliquely hint at what was missed, and the student picks up immediately. "Ah yes, proper nutrition is vital. This morning the nutritionist was consulted and Francis is currently on his proper daily caloric and protein needs, and his vitamin requirements."
The first student asks why Francis has swallowing difficulties and what could be done. You tell them that based on the gradual appearance of dysphagia and lack of focal neurological deficits, this is most likely due to age-related physiological changes and the effect of Alzheimer's disease. You inform them that this is quite common in the elderly, that further investigations are not necessary here, but also that this is a risk for developing or perpetuating chest infections.
After the explanation, you silently contemplate the best course of action. What will you order?
You recommend placement of a feeding tube and write out the necessary referrals. The following day, you go on a short but well-earned holiday to Southern France. When you're back in the ward, you notice that Francis is no longer there. The nurses tell you that after placement of the feeding tube Francis became agitated and kept on trying to remove it. He subsequently had to be restrained in order to prevent him from hurting himself. He died restrained several nights later. You feel awful as the magnitude of your mistake hits home ...
To your embarrassment, one of the students reminds you that there are no medical indications for parenteral feeding right now. You realize that he is right, and adjust your strategy.
You recommend assisted feeding with postural adjustments, and teach Francis swallowing maneuvers. You also recommend several changes to his diet. A few days later, the nurses note a marked improvement in his swallowing.
About a week later, you are hoping to get the discharge papers ready for Francis, when you learn he passed away last night in his sleep. His family and the members of the local veteran's association have come over to collect the remains, and are organizing a burial with military honors. You were always aware of Francis' prognosis so it doesn't come as a shock. The fact that you did the best you could do for him comforts you. Even though joyful outcomes cannot always be ensured when treating the elderly, you are glad that you are always able to ensure human dignity. Well done!