Some Musings on Care for the Elderly in General Practice
Dr Aine McCoy
Issue 12, April 2004
Many of my elderly patients tell me that it is no fun getting old. My standard reply is that the alternative isn't that great either!
The elderly present us with many challenges medically, socially and spiritually, but my experience in providing care to them has been an enjoyable one. I have come to appreciate some of the things that the elderly value in their carers. These include being a good listener, having a sense of humour, being there for continuity of care, being treated with respect and having their opinions valued, especially when they do not accord with yours.
It is easy to feel overwhelmed by the complexity of the clinical and social situations presented and the time pressure. Often we attempt to do too much in one consultation. It might be more beneficial to focus on one or two issues and see the patient again in a short while to deal with other issues. I have had to accept that they need more time and I plan for it, by doing something, such as having breaks in my appointment times to allow "catch-up".
Familiarity with our patients and their stories may mean that we do not listen as well as we should and we can easily miss a new symptom or a change in symptom, or indeed, our diagnosis may not have been correct in the first place. Locums or partners can be very useful in offering another opinion.
Be prepared to visit and have time set aside to do this. This is a service that our elderly patients appreciate greatly, even though it is more expensive than a surgery consultation and takes longer to do. It offers an opportunity to see our patient from a completely different perspective and always gives me a valuable insight into their life story.
Marigold, age 78 years, is single and has a rude overbearing attitude towards everyone in my practice. She has multiple medical problems including chronic lung disease (though she continues to smoke 80 a day), diabetes (still loves her chocolate and lemonade), but always attends for her three-monthly check-up. I had occasion to visit her some years ago and was stunned to see that everything in her flat was in suitcases or spread on the floor-certainly not the tidy flat that I was expecting. I did not dare make any comment - then or since - though I knew that she had no plans to move elsewhere. I have learned to deal with her attitude, for example when I am running late, I will offer her a choice of 10 excuses!
Daisy, age 92 years, is a querulous lady, widowed for many years and copes with poor vision living alone in a large house. She has a history of falling frequently, which I had always assumed to be caused by her visual problems and increasing frailty. I was asked to see her at the end of a busy surgery one day by a neighbour because she had fallen again. I was rarely called to see her so I obliged. When I arrived she had been lifted into bed and there I found her - obviously drunk. She likes to have her brandy at lunch for digestive purposes and perhaps another one or two at dinner. The neighbour wanted me to know that this state was a fairly common occurrence. I now regularly ask her about her drinking and point out that she may not be able to take as much as she had in the past and that it may be affecting her balance. I do not know if she has cut it back, because her blood tests have never shown any evidence of alcohol. I have learned to visit when asked and argue about the need for it later, though invariably I have found the request to be reasonable.
With all their medical problems it is easy to end up prescribing many medications. Beware of multiple medications and the problems of interactions- that is if the patient actually takes all the pills - many do not. While this can be a major source of frustration, it can also be beneficial!
We GPs know a little about a lot but should be prepared to admit when we do not know the answer. Patients ask our advice when they have important decisions to make and we need to be aware that they may have other unspoken issues to consider.
Petunia, age 90 years, lives alone but has two caring sons and their families. Despite poor sight and frailty she is well able to think for herself. Recently she was diagnosed with cataracts and was advised that an operation on her better eye might improve her vision usefully. She was also informed of the risks of the surgery, including the possibility of making her vision worse. She was adamant that if she went completely blind she would not want to live, then asked my advice as to the choice she should make. Reminiscing, Petunia told me about her own mother who had to have a cataract operation at the age of 83 years in the 1960s. She too was nearly blind and lived alone. It was Petunia who encouraged her to have the operation and her mother died soon afterwards. Petunia's only sibling blamed her for their mother's death. I advised Petunia to discuss her options with her own family and she has decided to go ahead and give herself the chance of better vision.
It is important to remember that we should operate as part of a team to offer the comprehensive service to the elderly that they require. It is helpful to involve the patient's family where possible and to work with them in a partnership of care. They often bear an intolerable burden in trying to keep their elderly relative independent in the face of increasing frailty. We have to accept that the price of this independence is the risk of an accident, though this can be lessened with aspects of community care and a medical alarm system. I encourage my frail elderly patients to plan ahead for the time when they can no longer cope at home and to make this choice before it has to be made for them. Frequently a crisis occurs which forces the patient to be accommodated elsewhere.
Lily, age 91, lived in her own home and was cared for by her two daughters, both visiting her daily. As Lily's confusion increased one daughter moved in. Community care was instituted to help ease the burden as Lily became more confused, incontinent and at times aggressive. Eventually Lily was admitted to a private hospital but a new problem arose - the care provided to Lily was never good enough, according to the daughter who had been living with her. This necessitated a change of hospital and even then issues about "neglect" occurred daily. The staff of the hospital were getting annoyed at the constant carping and so was I. Lily herself seemed to sense the emotions involved and would regularly have medical crises, which resulted in her being sent into the Public hospital. At the heart of all this was a mismatch of expectations and poor communication. I arranged a meeting with all concerned to set out the aims of our care. Lily's comfort was established as the main aim. As well, I spoke with both daughters, reiterating that they were part of the team in their mother's care and acknowledged their difficulties in "letting go" of their mother. Since then there have been fewer crises and we have dealt with them in a different way so that Lily has not required public hospital admission. The daughter's criticisms have not disappeared but we are all coping with them in a better fashion.
On a medico-legal note, while relatives can mean well, one must resist their requests for medical information about your patient without first getting your patient's consent.
Information about a patient can only be disclosed to their legal representatives who have Power of Attorney, in the case of those who are no longer capable of managing their own affairs, or to another person with the patient's consent.
When caring for patients in residential care it can be hard to establish a relationship with them when they cannot communicate with you in any meaningful way. I have found it helpful to have a photograph of them from younger days nearby-especially one of their wedding day. It gives me an idea of the person they once were, with hopes and dreams and good health - not the shell they have become.
Perhaps at the end of the day the role of a doctor as I believe Voltaire suggested is simply to keep the patient amused while nature effects the cure!
Dr Aine McCoy is a General Practitioner at the Peninsula Medical Centre, Miramar, Wellington. This article is based on a speech given by the author at The Nathaniel Centre's Inaugural Conference 'Spiritual and Ethical Issues in Aged Care' in November 2003.