Geriatric Depression Scale — use it and analyse the results wisely.
And no, not scales like gravity-based mass assessment or coverings on a fish’s skin.
Tag Archives: medicine
My father, the case in point/counterpoint
…we’re all overwhelmed with this. Today, Dad’s friend, a lawyer in south Florida, informed us that Florida law may consider Dad’s power of attorney (POA) signed in Tennessee invalid for the sale of the house in Florida because recent Florida legislation requires a POA to have witnesses in addition to a notary signature. Dad’s POA only has a notary’s signature. The Florida friend/lawyer’s investigating it more. I talked with Dad’s attorney in Tennessee this morning and he said he is willing to defend the power of attorney he witnessed as a notary.
In a little while, I’m heading over to see Dad and then drive home to attend to my wife’s health (and my sanity). Hopefully, Dad is stable enough to keep getting rehab for a few days and Mom can get some rest. Friends will bring food to Mom over the weekend.
BTW, last night, while Dad’s childhood friends, Philip and Terry, were visiting, Dad exhibited behaviour that indicates his thought patterns are very much mixed up, including putting the left houseshoe on the right foot, and then picking up a left tennis shoe to put on the other foot. He was able to tie a knot, though, and did, for the first time, lean over to kiss Mom goodbye when we left, so Dad’s thoughts are a mix of logical and illogical.
For instance, the bedrails were up and Dad kept trying to operate the buttons on the side of the bed to lower the rails, which didn’t work, but somehow he knew how to push one button to raise the headend of the bed to make watching TV more comfortable (behavioural feedback mechanisms are interested to observe, even in my father, the former professor).
He would grab the bedrail and pretend to climb over but look confused when he saw how steep it was from the bed to the floor and lean back into the bed. He saw Terry get in the wheelchair and then he decided he wanted to get in the wheelchair so we got him in it and let Philip take him for a spin around the rehab center. The nurses and techs said that riding in the wheelchair is Dad’s favourite activity right now; they encouraged us to do give him wheelchair rides as much as possible for his mental health. Interestingly, sometimes he can walk on his own and sometimes he’s like a ragdoll.
Terry said that this behaviour is normal for one of her grandchildren and we’re trying to get Mom to accept that Dad is like a little autistic child, who needs lots of love and encouragement no matter how odd his behaviour may seem at times. Just declare it Opposite Day and go with the flow. I think I’ll buy Dad some children’s books with pictures of cars — he loves to stare at the TV when a car race is on.
BTW, I sent an email to the case manager at the rehab hospital, asking for assistance in getting some questions of Mom’s answered:
- The Rehab Hospital brochure mentions having a neuropsychologist on staff. Why hasn’t the neuropsychologist reviewed Dad’s case and performed a cognitive test on him yet? Will the neuropsychologist be able to tell if Dad has FTLD in addition to ALS, bulbar option?
- Will the attending physician be prescribing Rilutek for Dad now that Dad has been diagnosed with ALS by the Medical Center staff?
- Will the Rehab Hospital be able to order a heart echo/ultrasound test that was not completed by the Medical Center? If not, can they assist in getting it performed offsite?
- Can the case manager assist Mom in filling out paperwork in order to submit a claim for Dad’s longterm care insurance policy?
There are days when I’m not a happy-go-lucky, patient man. Today is one of those days — just get me the answers I want and we can both move on to other subjects. Thank goodness I have a drive of five hours on which to focus my attention on mindless meditation.
Time to make a pledge to WETS-FM and then hit the road with tiny particles of rubber rubbed off through the heat and friction factor.
More thanks to give: Dr. Mann, NE State nursing students such as Miriam (as well as their instructor)…
Acronym of the day: FTLD
If you can’t read this, you’re either illiterate or possibly a prime candidate for FTLD.
Flowers for Algernon’s World According to Garp
Both my mother and I, tired from the up-and-down discoveries, research and changes of/about/for my father, experience back pain and stiff necks.
That in itself is not scary.
Nothing is scary.
Some forms of ALS are attributed to environmental factors.
Some neuromuscular diseases/syndromes are first diagnosed by treatment of back pain and stiff necks.
That in itself is not scary.
Some things are scary.
Writing this blog entry is scary enough without thinking there’s a local environmental factor or two (and probably not Max Factor but who can be sure that all the ingredients in cosmetics are safely influencing the environment while heating in the sunlight and mixing with methane in landfills?).
Any one who has common sense will remember that the bewilderments of the eye are of two kinds, and arise from two causes, either from coming out of the light or from going into the light, which is true of the mind’s eye, quite as much as of the bodily eye.
You see, humor is a set of scenes folded together like origami, which is, as you know, a combination of the words “original” and “pastrami,” not, as you might think, of the words “O” (as in the exclamation, not the Story of…), “rig” as in to construct something or fix a match (but possibly as in killing off large portions of the Gulf of Mexico), and “ami,” which some interpret as the acronym for the american meat institute but actually stands for the German colloquialism of the indigenous American people of Taiwan who use ambient intelligence to predict world events far in advance of us ever living as a world civilisation to prove their validity.
Therefore, watching the rise and fall of my father’s life in retrospect, with a partially predictive eye on the future, turns intelligent people into the bumbling idiots all of us are on a daily basis.
Because I’m tired, emotionally drained and otherwise able to hold a fork in my left hand while tapping the fingers of my right hand on a tablet…I’m not even sure where that image was going, it was so plain and ordinary.
Well, except to say perhaps my father, whose mental state is such that he knows how to put a shoe on and tie a lace into a knot but he doesn’t know a left shoe from a right shoe or even what type of shoe he put on one foot while picking up a different type of shoe to put on the other (and unfortunately, he isn’t Patch Adams trying to be funny), falling just short of ornery when someone tries to get him to put the correct shoe on his foot, whatever that means…I’m not even sure where that image was going, it so plain and ordinary for someone in his condition.
I took my mother to her first ALS support group session tonight, meeting professionals like Michelle, who has worked in the dental industry for over 30 years and had several useful tips for people with swallowing difficulty and/or advanced stages of ALS to maintain dental health, as well as meeting family members of ALS diagnosees and one ALS diagnosee himself.
Oh, the tangled webs we weave in our social interaction.
I just want to be that hermit living in the woods, digging ditches by day, that my mother reminded me again yesterday I said I wanted to be when I grew up.
Instead, I’m here, at this keyboard my father used for years. Well, no, this keyboard is only a year or so old, belonging to the set of accessories/peripherals that went along with the desktop minitower Dell PC labeled inspiron 531 that uses Windows XP and is probably older than I thought. Anyway, I sit in the chair that has rolled back and forth in front of this old student desk that my father has used for a computer station lo these many years.
Sounds bounce around in my thought set, mixing languages, nonsense sequences and other imagery one can associate with the upbringing of a member of our species, this set of states of energy devoted to getting more Earth-based sets of states of energy off this planet and away/out.
The opposite of the hermit’s dream.
‘Tis easy to be mixed up.
‘Tis easier to apply the mix to practical solutions, rather than figuring out the relationship between Solutia and Monsanto or ALS and FTLD.
Thanks to many, including Marc, Andy, Sagar, Barbara (happy belated birthday), Pal’s #13, Traci, Monica, Patty, Daniel, Christine, Allison, and many more…
This is Manic Rick Hill*, signing off before the caffeine overload (an ode to Pepsi is due except I don’t want to diss my cousin Barry’s employer, Coca Cola) kicks in and assists/facilitates my burst of wordiness that has no meaning in the weoinb2323:”3$^T#NdSLKER.
*you have to guess which Rick Hill am I, having a name that is rather commonly uncommon in these parts:
Laughter in Medicine
My father has always been a serious fellow around me but he has had his funny moments, too.
When I was in secondary school, my father chaperoned many an event, earning himself the nickname “Cool Dad.”
So, while I mentally compose funny bone ticklers to flesh out here in later blog entries, today’s info-stuffed minimal verbosity includes two links for those seeking silly respites despite serious riffs on ALS-related syndromes/diseases:
Repost of the day with word of the day: atelectasis (Gesundheit!)
As I continue the walk, with family and friends, down the path of my father’s health changes, here’s a repost of information pertinent to the issues we face:
Normal chest radiograph in terminal respiratory failure due to amyotrophic lateral sclerosis.
To the Editor: We report the case of a patient with terminal respiratory failure due to amyotrophic lateral sclerosis (ALS) who had a normal chest radiograph (CXR) 13 hours before respiratory arrest and death. This case shows that a normal CXR in the setting of severe neuromuscular disease cannot be used as evidence of even short term respiratory stability.
A 48-year-old man with end-stage ALS presented with respiratory insufficiency and weight loss. Five months before his admission, he lost the ability to ambulate without assistance and he developed progressive difficulty speaking and swallowing. He subsequently lost 50 pounds and became essentially bed bound.
His height was 73 inches and his weight was 120 pounds. His respiratory rate was 18 breaths per minute and breathing was mildly labored. Oxygen saturation by digital pulse oximetry was 97% while the patient was breathing ambient air. His speech was barely audible. His cough was weak and he was tetraparetic.
A bedside frontal chest radiograph demonstrated normal lung volumes and no cardiopulmonary abnormalities. Vital capacity measured at the bedside was 400 mL. On hospital Day 1, the patient’s breathing became increasingly labored. He was placed on bi-level positive airway pressure ventilation, but his respiratory status deteriorated progressively. He developed obtundation and arrested. Per his directive, he was not resuscitated. He was pronounced dead as a result of respiratory failure 13 hours after a normal CXR.
Patients with ALS commonly die from pulmonary complications. (1) Common respiratory sequelae include atelectasis, pneumonia, copious secretions, aspiration, and obstructive sleep apnea. Chest radiographic abnormalities are frequent in end-stage ALS. Atelectasis is seen early in respiratory failure and often persists despite assisted ventilation. (2) Conversely, clinicians may be erroneously reassured by a normal CXR. To our knowledge, no study has correlated radiographic findings with the degree of respiratory muscle weakness or with the incidence of respiratory failure in ALS.
In conclusion, clinicians should not be reassured by normal chest radiographic findings when assessing a patient with ALS for possible respiratory insufficiency. Clinicians must assess other clinical indicators, including pulmonary function, symptoms and signs of respiratory insufficiency, as well as imaging studies when trying to diagnose and/or predict respiratory failure in patients with ALS. (3,4)
Christine Won, MD
Dipanjan Banerjee, MD
VA Palo Alto Health Care System and Stanford University
Palo Alto, CA
Paul Stark, MD
VA San Diego Health Care System and University of California
San Diego, CA
Ware G. Kuschner, MD
VA Palo Alto Health Care System and Stanford University
Palo Alto, CA
References
1. Lechtzin N, Rothstein J, Clawson L, et al. Amyotrophic lateral sclerosis: evaluation and treatment of respiratory impairment. Amyotroph Lateral Scler Other Motor Neuron Disord 2002;3:5-13.
2. Schmidt-Nowara WW, Altman AR, Atelectasis and neuromuscular respiratory failure. Chest 1984;85:792-795.
3. Rabinstein AA. Wijdicks EF. Warning signs of imminent respiratory failure in neurological patients. Semin Neurol 2003;23:97-104.
4. Similowski T, Attali V, Bensimon G, et al. Diaphragmatic dysfunction and dyspnoea in amyotrophic lateral sclerosis. Eur Respir J 2000;15:332-337.
Hard work spotlights the character of people: some turn up their sleeves, some turn up their noses, and some don't turn up at all. --Sam Ewing
COPYRIGHT 2006 Southern Medical Association
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2006, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.
Lost in Allemagne
Whatever it may be, it is what it is. I no longer have a mind, or semilogical thought set.
Where is the guy who can spin off cantankerous cacophonies of kaka like it’s nobody’s business?
A new list of names to add to the list of names of people to thank for being people.
Can I be too tired right now to name them?
Where is the amateur professional amateur when I need him to stand in my stead and mount the steed like an Android tablet that suddenly displays a need to find the mount drive named something like /mnt/, which amounts to mountains of rubble and gibberish rubbish to the noncomputersavvy. Savvy?
Of course not.
My father is dying, dying, dying and I’m past the point of pain, pretending to pretend my father is there in some form of his old capacity while pretending in pretense, past tense, tension (the hyper kind), that he’s like a newborn child all over again, like adopting an autistic child with no clue which clues to the child’s nonclues indicates the child’s needs without pretending.
Is my father clueless or stubborn? Is he ignoring or is he tired?
He never liked dwelling on discussions about his health, his PRIVATE health, with strangers.
But he loved talking.
Now he grunts, coughing out sounds we interpret as “yes” or “no” to the best of our ability until he indicates we were wrong.
He is weak, getting weaker, never the weakest this week. Weebles wobble but they don’t fall down.
To have these moments with him in his time of indiscernable thought patterns.
To read much, little or nothing in his eyes, from when he chooses to look back with a blank stare.
Not even a smile.
Is it worth writing about the shriveled hands, the sunken cheeks and hollowed-out eye sockets?
When the family chooses to put in the feeding tube, the PEG line, these are the consequences we get to face.
It is up to me to serve as a warning to the rest of you — resist the temptation.
I don’t want the last memories of my father to be these moments of diminished capacity, well beyond the twilight zone of believability.
I believe I have no choice.
Suffer the insufferable.
Go with the flow. It’s all relative — many have suffered worst fates with friends and family.
And yet, not so.
Time to revise my living will — there will be no PEG line for me, no stretching my life into wide-eyed stares with no productive, contributory communication to give back.
Let me die in strength.
Let me fight the good fight while I have the capacity to say no.
While I have the fingers to type or, at the very least, the ability to dictate via brain probes.
Something…anything but this.
I am beyond crying.
I am tired of being tired of being tired.
If my thoughts aren’t worth reading, plop me in a wheelchair and push me into the woods.
That’s the joy of having no children.
Let me feed wildlife with my set of states of energy in entropic flux.
Where labels have no meaning to an ecosystem designed to eat the weak and the dying in an effort to convert energy into the ebb and flow of species sets of states of energy in regenerative reproductive mode.
Auf wiedersehen, Vati!
More People to Thank…
Thanks to Judy, Robin, Shawn, Amy, Lisa W, Marla, Carol, Ethan, Heather, Courtney (did I already thank Jeff Gulley and Andy of Ambulance Service of Bristol?); Food City, Marie; Miss Bea’s; Pal’s; Amis Mill Eatery, Tanima; El Paraiso, Lucy; Big Lots, Juanita, Lana, Tori; Advance Auto, Aryonna; Healing Grounds coffee shop, Brandy (barista); Zoomerz 69; Cupboard/BP; VA/CLC, Heidi; Col. Heights Presbyterian church staff and parishioners, neighbours providing food/emotional support; MassMutual, Christine; more to follow…
Chemistry… “Live it. Love it. Wear it.”
While the world stares blankly at the U.S. arguments about national “universal” healthcare, I delve into the healthcare provided to one person: my father.
I observe and listen.
I take the advice of medical pros like Dr. Little and delve more deeply into the mixture of medications poured down my father’s throat on the advice and scripts of his doctors.
Drugs like pyridostigmine, prednisone, and paroxetine given all at once.
What if the medications are causing side effects that doctors are treating as symptoms, prescribing more medication to treat the symptomlike side effects that causes more side effects which look like new symptoms, etc.? A vitreous cycle, wouldn’t you say?
You see where I’m going with, don’t you?
For the sake of keeping this civil, let’s call it “human nature.”
What is that phrase I tend to forget in moments like this…?
To err on the side of caution is good human medicine, to forgive Divine for bad acting is unnatural?
Something like that.
More like to wade Kendrick Creek during one’s spring break is fun, to build a bridge on Gibson Mill Road in summerlike heat is exhausting.
I just hope we can get Dad back before it’s too late.
If any of him is still there…sigh…kinda like USA soccer/futbol, here the next moment, gone in an Olympian tie the next…
“Customer Care – Incident Created”
In this day and age of multiple personality disorder — that is, our combination of official government identifications (driver’s licence, voter ID card, medical ID card, etc.) and online personalities (email address, social media identities (real and/or imagined)), etc.) — do we know who we are when we no longer know who we are?
While we work with medical professionals in private practice and public hospitals (a thanks to the folks at Holston Valley Medican Center and HealthSouth Rehab Hospital) to get my father on a track where he can have an acceptable, if not good/great, quality of life considering his conditions, my family works in the background to sort out my father’s multiple personalities.
For instance, my father kept Post-It notes of some of the usernames and passwords associated with his online personalities but not all of them, especially the most important ones.
His official government identification cards are up-to-date and don’t need fixin’, as we say around here.
However, working through the bureaucracy of getting help when help is needed most — a medical emergency — is just short of a nightmare for those of us able to sort through the payment options and insurance coverages that are written to accommodate as many diagnoses as are currently available in legible written form by the medical profession.
Woe be to those whose family members have symptoms that can’t readily be grouped into an official syndrome or disease.
I could wax and wane through many a lighted Moon cycle on the current state of the modern medical scientific community but suffice it to say that any view 1000 years hence marks this time, like all looks back into history, as rather barbaric, archaic and borderline misinformed.
Unfortunately, I don’t have a fast-forward button to take my father into a future where his conditions are rather curable by enlightened practitioners.
I have to deal with the training and knowledge at hand, such that it is.
Thank goodness, compassion, care and comfort are rather universal — human touch, in other words, is good for most of us, in one form or another.
My father responds well to communication with fellow members of his gender. Guy-to-guy gatherings are his thing and he perks up when men ask him to perform manly tasks.
He does not want to be babied or treated weakly by women.
Otherwise, all is well that progresses well.
Me, I don’t mind attention by females in medical professional roles but I’ve noticed my father responds best when treated by men — doctors, nurses, therapists and specialists.
Probably a generational thing as well as social training — I am a child of the 1960s/1970s whereas my father is a child of the pre/during-WWII era, with other subcultural nuances thrown in for good measure.
Something the medical community should take into consideration when vocalising concerns about getting more people involved in seeking certification for jobs/roles in the medical field.
Healing is not just application of chemical treatments — treating people like desired monoculture grass lawns — it’s also understanding where the patient is coming from and wants to be treated.
The online world is no different. How do we create a system so that when a person’s ability to recall important online identity tags diminishes, family members can step in and help without having to figure out the unique character set combinations the person’s brain created to protect online personalities, especially where bill payment and medical information access is critical to keeping the person healthy and out of financial trouble?
People to thank with more to follow: Benjamin, Amanda, Tina, Martha, Mary, Sue, Jennifer, Joyce, Glenda, Brenda…
treetrunkdings 