Geriatricians, physicians, and family caregivers writing on KevinMD about growing old: dementia and Alzheimer's disease and the biomarkers and drugs argued over since 2010, caring for aging parents, nursing homes and long-term care, polypharmacy and when to stop screening, falls and delirium in the hospital, the shortage of geriatricians, and longevity medicine. One maintained record draws on this archive: Aging and dementia: what physicians say, in their own words.
Just a few years ago it seemed that advocates for health care transparency had scored a big victory. The Centers for Medicare & Medicaid Services (CMS) announced that they would rate nursing homes by awarding five stars to the best and fewer stars to lower-quality facilities. Families searching for care for loved ones would have access to a familiar rating system to help them make choices. After all, star ratings for …
Read more…
How to choose a nursing home: Why 5-star ratings may be wrong
Sometimes my day is like a book. The first chapter may begin in the darkness of a self imposed corner as a phone call is made. A voice, full with the thickness of slumber, answers unexpectedly.
“I think today is the day.”
No matter how many years I have been discussing death I still find myself using poor euphemisms. The bane of medical school teaching, I often struggle with the directness. “Your mother …
Read more…
One doctor’s day: Everything comes full circle eventually
The electronic medical record that my office uses features a clinical protocol button that we are encouraged to click during patient visits to remind us about potentially indicated preventive services, such as obesity and tobacco counseling and cancer screenings. I once tried it out while seeing a 90-year-old with four chronic health problems. The computer suggested breast cancer, colorectal cancer, and cervical cancer screenings: three totally inappropriate tests for the …
Read more…
Cancer screening in the elderly: Don’t be stupid
“If a tree falls in a forest and no one is around to hear it, does it make a sound?”
Chances are that many of you have duked this out with your college roommates back in the day, but how about this one? “If a doctor and a patient make an advance care plan, but when an emergency happens, nobody can find a copy of it, the proxy doesn’t know what’s …
Read more…
DNR/DNI: More code than status
William was doing great. His C. Diff was finally gone after a month taper of vancomycin. He was stronger. The nursing home staff reveled in how much progress was being made over such little time. It seemed every one was ecstatic, except for, of course his family. Every step this octogenarian took forward was accompanied by a litany of concerns and complaints from his daughter.
If he was not gaining weight, …
Read more…
Why do some patients go to the doctor in the first place?
The old adage “time is money” holds true, especially in health care. Apparently the medicine time crunch spans two midnights.
In October 2013, Medicare enacted a provision that changed coverage for hospitalized patients. The “two-midnight rule” states that a patient will not be covered as an inpatient unless their hospital stay is expected to cross two midnights. The end result is that many seniors are placed under observation, even if they stay …
Read more…
Seniors pay the price for Medicare’s two-midnight rule
We all want the advantage. We put our kids in special preschools so they have the advantage. We work 100 hours a week so our kids can do 8 activities and get the advantage. Tall people have an advantage, we’re told. Poor people are “disadvantaged.” Well folks, there are a whole bunch of senior citizens in Massachusetts who are about to get disadvantaged starting September 1.
UnitedHealthcare (UHC) will be Read more…
The effect of dropping doctors from Medicare Advantage plans
It was just a regular hot and humid Saturday morning in Miami, and I was on my way out of a local Walmart after buying a few items. As I walked to my car at the end of the parking lot, I heard a voice asking me “Son, any change?” In a neighborhood that is known to have a disproportionately large amount of vagrants, I did what I usually do …
Read more…
The civic responsibility of physicians in our community
Mr. Katz sat on the edge of his chair in my clinic room, teetering as if he might fall at any moment. He was 86-years-old, and his thin body had become weak and tired. But his angry eyes, like a petulant child, stared at me.
“Doc, you should have just let me die,” he said to break the ice.
I had just discharged Mr. Katz earlier in the week from the hospital. …
Read more…
How physical therapy gave an elderly patient hope
A few months ago, the father of a primary care physician came into the emergency department with syncope. He was 102 years old. His age was more than double his heart rate. That may or may not be bad but it certainly is often a reason for more testing. The senior resident seeing the patient ordered an EKG, a battery of labs, a head scan, and anticipated admitting the patient …
Read more…
We need more clinical time outs
This quarter of medical school has by far been my favorite, because almost everything we do has an explicit clinical correlation. Each week we work in small groups of 10 or so students to go over patient cases, practice respiratory and cardiovascular (our two organ blocks this quarter) physical exam skills, and interface with real patients in the hospital. These experiences have been both exciting and humbling, and two in …
Read more…
A passion for family-centered care
Her wary eyes, magnified from her thick-lensed spectacles, watched my every move as I pulled room 21’s curtain to the side and entered her room. In her early eighties, it was apparent to me that my entrance into her life was more important than the abdominal pain that brought her to our emergency department. In the corner sat a slight man with wispy gray hair poking out from the border …
Read more…
How bingo kept a patient going
Agnes was out shopping at her local corner store. At age 82 her body was beginning to show typical signs of aging. She had survived breast cancer surgery, a hip replacement, and cataract surgery. Her doctors told her she had osteoporosis and low vitamin D. She took medications for her hypertension, cholesterol, and osteoporosis. Her spine had begun to curve and her gait was a few steps slower.
Yet, with her …
Read more…
CPR without informed consent in the elderly
Today, a patient attacked me. A nurse got kicked. Another punched. I was gouged to the point that blood was drawn. The patient was neither intoxicated nor psychotic. Rather, she was a meek 92-year-old grandmother, and she was terrified. It took five of us to hold her down, as she summoned the strength of a woman fighting for her life.
Linda is an elderly woman with moderate dementia. She is blind …
Read more…
When we torture our patients
You were supposed to die of cardiac arrest as you circled toward home plate. Or of a brain aneurysm in the summer during one of your countless hikes through the mountains.
You weren’t supposed to die here. Not in a hospital bed, inhabiting this fragile new body, with an oxygen tube in your nose and tumors in your lungs.
Two days before you left us, I traveled home to visit you. I’d …
Read more…
Saving my grandfather
When I read news articles about caring for elderly parents at a distance, I sometimes shake my head. There’s a tendency to put the best spin on the experience: As long as you contact the right people, get the right information and treat the ups and downs as just part of life’s challenges, you’ll be fine. You can do this!
I find myself wondering when the author last talked to a caregiver …
Read more…
Family caregiving is hard and imperfect
As I explained his options, my patient’s initial shock turned to disbelief. I told the 84-year-old man that Medicare would pay for treatment of his urinary tract infection if he received infusion therapy at a nursing home, but it would not be covered if he opted to receive the therapy at his own home.
We calculated that the four weeks of therapy at a skilled nursing facility would cost Medicare about …
Read more…
Medicare should cover infusion services at patients’ homes
Consider this scenario.
You are getting older, and are concerned about the costs of nursing homes and long term care. So, you decide to get expensive long term care insurance to protect your family from these costs. The policy will pay some of the cost of long term care if you develop cognitive or physical disability. All you have to do is keep making payments on the policy until you have …
Read more…
Long term care insurance: The premium catch
A 92-year-old woman with a history of stroke comes to an emergency department and is found to have fractures of her cervical spine. Neurosurgery sees her but doesn’t think she needs surgery. The emergency department physician tries to admit her to the hospital as she has a new functional disability due to the fall but the hospitalist refuses as the patient doesn’t meet criteria for inpatient admission.
And there she sits …
Read more…
Options for the injured older adult in the emergency room
Home visits are hard, there is no doubt about it.
I felt like I had been driving for hours. The thirty minute travel time showing on my GPS was woefully understated due to the arctic temperatures and colossal snowfall. My jacket and clothes felt caked with dried salt rubbed off from the car or somehow accumulated from the ether. I pulled the key out of the ignition and braced for the …
Read more…
When a home visit invigorates
