Older Patients, Wiser Care

Dear Dr. K: "In my written instructions for family and caregivers I’ve stated: "If I'm living, let me live. If I'm dying, let me die." Is this enough? I’d appreciate some "informed advice" on this, with alternate suggestions."

Let me start by congratulating you on having taken some very important steps that I wish all my patients would complete! First, you’ve thought ahead to a time when your caregivers may have to make medical decisions on your behalf. Second, you’ve made the effort to document your wishes; written information in an advance directive or living will can be very helpful to all involved when a crisis hits.

The trouble, however, is that your instructions may be hard to follow. That’s because in advanced illness, living and dying often look more like a spectrum, where one slowly shades into the other, rather than like two distinct states that are easy to tell apartrt...  Read more

Dear Dr. K,

My 82-year-old mom's doctor ordered a mammogram and pap recently even though she has pretty significant dementia. I'm not sure she would even understand a cancer treatment if a problem were found. Are these tests really necessary?

Probably not. Recent studies and expert guidelines have suggested that it’s often appropriate to dial back on cancer screening as people age, especially if they have dementia or another condition that's likely to limit life expectancy. Plus, as you so perceptively point out, in the case of Alzheimer’s or other dementias, cancer treatments can be a particular ordeal, since the patient often doesn’t understand why uncomfortable treatments and procedures are being done.

Ideally, the decision to refer an older woman for cancer screening would be made after the doctor and patient had considered the overall health state of the patient and agreed that the benefits of screening were likely to outweigh the burdens...  Read more

Dear Dr. K,

After my dad's heart attack, I was surprised when the hospital wanted to discharge him after less than a week. He still seemed weak and disoriented and has slight dementia. I was hoping they'd monitor his diabetes and high blood pressure, too, as these had been giving him trouble. Sure enough, the day after he got home he fell in the night and broke his hip! Should I have fought harder to keep him in the hospital -- and if so, how??

Without knowing the specifics of your father’s case, it’s difficult to say whether it would’ve been better for him to stay longer in the hospital.

The time right after a hospital discharge is *always * dicey, because it’s common for older people to find themselves in a condition similar to your father’s:

• Weak because they’ve just survived a major illness, and usually have been much less physically actitive than when at home...  Read more

Dear Dr. K,

What’s the best way to treat constipation in an older person? My father has chronic back pain due to arthritis in his spine. Taking a Vicodin tablet three times a day really helps, but it seems to make him constipated. His doctor recommended he take Senna every day, but I’ve always heard that one shouldn’t use laxatives for more than a few days at a time.

Constipation does become more common as people age. So it’s unfortunate that all the opiate pain-killers many older adults take (including Vicodin) make constipation worse.

Luckily it’s usually easy to find a way to keep the bowels running relatively smoothly, even while taking a transit-slower like Vicodin. And although the packaging of most laxatives implies that one shouldn’t use the product chronically, several of them can be used on a very regular basis, without apparent harm to the bowel...  Read more

Last holiday season, I shared with you a list of 12 advantages of getting old, which had been given to me by my 83-year-old patient, Mr. R.

A few months ago, I had to say goodbye to Mr. R and many other patients I’d known for years, as I prepared to move my practice from the VA’s geriatrics clinic to the Over 60 Clinic in Berkeley, California.

“Doctor, remember that list I wrote for you last year?” Mr. R said at our last visit together. “I came up with a few more points about getting old that I thought you could share with your readers.” He pressed a little sheaf of notepaper into my hand.

Despite Mr. R’s wry title, some items made me laugh out loud. Better yet, each one reminded me of an * opportunity * we all have to better support an aging relative or friend. So here’s his list - and my caregiver twists to them.

The Disadvantages of Old Age, and what caregivers can...  Read more

Dear Dr. K: What are your thoughts on the new bracelet called I-Renew, which works on the biorhythms of the body? It’s supposed to help with energy and balance. My father has dementia, so I bought him that bracelet -- and can verify that it works very well for him He no longer stumbles or wobbles as he walks, and he no longer needs to use a step-stool to climb in my pick-up truck. But others say this can’t be true.

I’m happy to hear that your father’s balance seems to be better these days. But is it the bracelet? Seems doubtful to me. I’d never heard of this device before your question, but a quick Internet search reveals many complaints about this product posing as a miracle cure.

How is a concerned caregiver to know if something’s a scam or an unconventional treatment developed outside the usual medical model?

Gadgets, jewelry, magnets, herbal supplements, exotic extracts – patients and caregivers often ask about alternative treatment products in my practice, as they search for ways to address the many challenges of aging...  Read more

Dear Dr. K,

I'm worried about nutrition for my 84-year-old aunt, who lives alone. She has really bad arthritis, so it's hard for her to get out of the house, and she can't cook the way she used to. She's always been slim, but these days I worry that she's getting even skinnier! Would you recommend that she start drinking something like Boost or Ensure, and would I need a doctor's prescription in order to get it? I can't shake the feeling that she really needs to be eating better than she does.

Unintentional weight loss should always be a red flag for those of us caring for elders, so I’m glad this issue has caught your attention.

For some people, a fortified drink like Boost or Ensure can be really helpful. The key, however, is to first make sure that your aunt’s weight issues really are best addressed with this type of nutritional supplement.

To figure this out, you’ll want to do a little basic investigation as to what might be behind the weight loss...  Read more

Dear Dr. K,

Why do doctors often avoid talking to older people during primary care visits? I’ve been bringing my elderly mother to see a doctor whom I’ve heard is pretty good. But it bothers me that he often ends up peppering ME with questions rather than talking to my mom. She does have some early Alzheimer’s, but she’s the patient, and I don’t think the doctor should be treating her like a child, or like she’s not there. Should I think about changing doctors?

It sounds like you’re not very comfortable with this doctor’s style. It’s certainly possible that another doctor might be a better fit for your mother and you.

I’ll admit, however, that even as a geriatrician who’s used to patients with dementia and who always starts the visit by talking with the patient, I still often end up questioning the caregiver companion. In fact, just the other her day, a patient’s son frowned at me and asked, “Why aren’t you asking him...  Read more

Dear Dr. K,

How can I convince my mom to get a flu shot? I want her to keep up with recommended preventive care, but she’s been pooh-poohing me, saying she’s already lived through plenty of flu seasons. Also, I’ve heard there’s a new stronger flu shot available for older people this year. If I can talk my mom into getting vaccinated, should I push for her to get this new shot, or the usual one?

I’m not surprised to hear that your mom is skeptical of the flu shot. My own primary care clinic is currently offering flu shots to everyone who comes for a visit, but just this past week, I’ve been turned down by about a quarter of my own patients!

Here are some of the common reasons I hear for resisting vaccination, along with my usual responses:

• ”You can get the flu from the flu shot.” No, you can’t get the flu from the flu shot, because the injected flu vaccine contains only killed influenza virus...  Read more

Dear Dr. K,

What is the right blood pressure for a woman in her 80s who has kidney problems? My aunt’s doctor recently sent her to a kidney specialist, because her kidney function is low and her blood pressure is too high. But the kidney doctor says her blood pressure is fine, and that it shouldn't be below 140 at her age, because the arteries are inelastic. Is it true that a pressure of 140 is okay? My aunt’s regular doctor has always told us to aim for less than 130.

Most geriatricians would side with the kidney specialist on this one. Although high blood pressure is a major health problem for Americans overall, as people get older, it gets more and more likely to develop side effects from blood pressure medicine. So making sure that people aren’t on too much blood pressure medication is common practice in geriatrics, especially if there’s been any concerncern about falls...  Read more