Category Archives: aging

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Elder care: stairs

Most of us do NOT live in homes practical for aging. My house has four steps in the front and five in the back to get in and out. The main floor has almost everything needed if I cannot climb a flight of stairs: only the laundry is in the basement.

I am helping a friend in her 80s. The issue, from my practical and pragmatic Family Medicine standpoint, is that she is falling. She told me that she was falling, five times in a day, in November. I got involved right away, because she had a surgery canceled because of it. She has three specialists and a primary. I called them all and took her to the emergency room first and then to her primary.

We asked her primary for disabled parking and for home health services. In Washington State, if you can’t leave your house except to the store or the doctor, you qualify for home health. I also fussed about her blood pressure, but her primary thought she was fine.

The thing is, we should not always have a blood pressure goal of 130 or less systolic once we hit 75 or 80. With weight loss, people can drop a blood pressure point for each 2 pounds lost. The blood pressure range that is safer at age 75 or 80 is to keep it around 140-150, unless the person has heart disease or congestive heart failure. Over 150 is getting too high. The brain must get good oxygen by blood flow and if it doesn’t, there are sensors in our neck that make us faint. That can be a full on loss of consciousness, or just a decrease and drop to the floor. There are some instances where the blood pressure still needs to be kept down at 125-130 systolic: bad coronary artery disease and congestive heart failure especially. But being able to stand up and walk is rather important to elder health.

The distraction for my friend’s physicians is that she has had cancer for three years. We are told that she needs an MRI of her head to rule out brain tumors, metastases from her cancer. Yes, brain tumors can cause falls, so that does need to be ruled out. My friend only falls when standing, sometimes at the counter, gets lightheaded and once has had a full on syncope. No chest pain or heart racing.

It took two months to get the brain MRI, which is negative. We saw her oncologist this week and I pushed for her cardiologist to see her sooner than June. He saw her yesterday. She is on medicine for a heart arrhythmia, but it doesn’t sound like her arrhythmia is acting up. He’s still checking: a monitor and heart ultrasound, but meanwhile he says, “I don’t tell many people this, but you need to drink more fluid and eat more salt.”

“They told me low salt. I stopped salt when I cook.”

“Start salt again and more fluid and return in 3 weeks.” She has been falling 1-5 times a day in her home. She lives alone. She is stubbornly resisting leaving her home and I am ok with that. But, it would be most helpful for her health if she was not falling. That is the priority here. She will not live forever, but she wants to stay in her home. Let’s help with that.

I am NOT saying that everyone over 75 should increase salt. If a person has bad hypertension, or heart disease, or congestive heart failure, they should not increase salt unless their doctor has a specific reason. And heart is the number one killer, so there are lots of people who should continue to eat a low salt diet. But falling and breaking a hip is also a killer.

My friend has three steps to get out of her house. The first day last week that I took her to get labs, she fell three times. “But Jim, I’m a doctor, not a nurse!” Ok, I am not a good nurse. However, we got her back inside after labs and getting the CT scan contrast for her to drink. She has not fallen when I have gotten her in or out since. I’ve had to enlist help twice, since she’s taller than me. Going down the steps is worse than going up. Home health is doing physical therapy and she has a raised seat on her commode. That is good, except those are the muscles that help us go up and down stairs. She has a walker too. She is still falling, because to cook, one has to let go of the walker, right?

So if someone wants to stay at home, think about the home. Are there steps? How strong is the person? Do they have the resources to pay for around the clock care if they become bedridden? I am practicing getting down on the floor and back up every single day, because I want to be strong. I have an upstairs and a basement, and I am going to continue with stairs for as long as possible. If I break my leg, those four front stairs are going to be an issue, but I am thinking about it. Perhaps I should design a decorative ramp, or a sloping earth entry.

Will the house accomodate a wheelchair? Is there a bathroom and a bedroom, as well as the kitchen, on the main floor? Is there clutter? I know I am supposed to keep the floors clear to reduce fall risk. I had one person who kept falling at night because he wouldn’t turn on a light. “It would wake my wife and disturb her,” he said. “It will disturb her more if you break your hip.” I said. “Turn on a light or a flashlight or something.”

Harvard Medicine agrees: https://www.health.harvard.edu/staying-healthy/master-the-stairs

Be careful out there. Or maybe in there.

For the Ragtag Daily Prompt: Elder care can’t be laissez-faire.

The photograph is not my friend. This is Tessie Temple, my maternal grandfather’s mother. I do not have a date nor who took the photograph. Another photograph is stamped on the back: Battle Creek. She must have gone to one of the famous sanatoriums, like Kellogg’s, for rest or the cures.

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Medicare Disadvantage

Medicare Advantage plans, from for profit insurance companies, are being rebranded Medicare Reach.

They seem like a good deal. They are if you are healthy forever! So what is the catch?

In Michigan I go to look at a nursing home with a friend. The administrator shows us around. Small rooms with two beds. We also look at an assisted living. Much larger rooms, the friend can stay overnight in the private room with the parent, at a cost of $4000.00 per month. Her insurance will not cover it.

But back to the nursing home. The administrator tells us that it’s good that her parent does NOT have a medicare advantage or medicare reach plan. “It is nearly impossible to get the insurance companies to approve a rehabilitation stay at a nursing home.”

“Really?” I say.

“Oh, really.” She says. “The insurance companies certainly don’t want you to know that when you buy their “deal”.”

So, the for profit insurance companies want you if you are of medicare age and are well. BUT the catch is that they really don’t want to cover if you are sick. Think carefully before you buy a pig in a poke!

Physicians for a National Healthcare Program is working to stop the insurance companies from skimming profit off the healthier elders and then abandoning them when they are not healthy. I wish that the United States citizens would clue in, get mad, and vote for single payer! Write your congresspeople and put pressure on them! They listen to money but in the end, they live by votes. Make sure you look at the fine print, because the insurance company is there to make a profit off you, not preserve your health.

The picture is Mordechai, our plastic clinic skeleton, distrusting Profit-Over-Health Insurance Companies.

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lair

alone and sad
lurk in your lair
information
rotting there

you say you read
what I write
but not what or when
or day or night

collect words
webbing glue
word mummies
stick to you

you don’t connect
you don’t share
you say you never
never care

your web is touched
vibrates fast
fangs extend
webbing cast

you bite your victim
in spite of screams
anesthetize
steal their dreams

I ask questions
you scold me coldly
I break the web
fight poison boldly

read my words
as you will
I’ve escaped your web
as others will

your web is old
you’re growing slow
your poison fails
your victims know

you end alone
sag sagging web
your victims glad
when you are dead

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A second darker take on the Ragtag Daily Prompt: dream world.

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abuse, enabler style

I am raised by a family of triangulating enablers and enablees.

The enablers are my mother and two uncles. They are very very smart. Let me qualify that: they are very very smart intellectually. Emotionally, not so much.

The two uncles have PhDs and are professors. They marry wives that are lessor in their view. One tells my mother that he wants a woman who is not as bright as he is. I don’t know if she is less bright, but she is a hella better athlete. I also have the impression that she had a time where she drank too much.

The other uncle marries a woman who tends to be a hypochondriac. He takes her to India, where she gets polio while pregnant. She is then a sick hypochondriac, which is very difficult. The ill can control their families by planning things and then getting sick at the last moment. On the other hand, chronic fatigue and fibromyalgia are very real and we are on the edge of figuring them out. That uncle divorces his wife and I instantly like both of them better. They stop being a weird unit and are suddenly individuals.

My mother tells me, when I am in college, “I wondered if your father was an alcoholic when I married him.” I want to hit her. She won’t leave him, she won’t stop enabling him, they scream at each other at 2 am often. Now I wonder about that and conclude that either screaming at someone was something she needed or she was an alchoholic too.

After my mother dies, I ask my uncle, what about his parents? After all, the three of them learned enabling somewhere and it pretty much has to be at home.

My uncle tells me his parents had a PERFECT marriage and that my grandmother LOVED being the wife of a physician and professor.

Um, so, then, why did she pay my tuition to medical school, uncle?

And I think about my mother’s stories. Once, she says, your Uncle Jim bet his friend Dick that Dick was too chicken to shoot a cigarette out of Jim’s mother’s mouth. Ooooo. With a rubber band shooter. Yes, my grandmother. Bob took the bet and succeeded. My grandmother roared with anger and the two boys ran like hell and hid.

And someone in the family tells me: your grandfather helped your grandmother control her temper.

There it is. The enabler/enablee.

The enablers die first. My grandfather of cancer at 79, my mother of cancer at 62. The cousins are all angry at me because I won’t follow the family rules and triangulate in a satisfactory manner, and I don’t care any more. I am ignoring them. I got my father’s banjo back and I am done. The two cousins I own land with jointly are not the worst triangulators.

I have to remind myself: for them, this is love. For some people, controlling or being controlled is what functions as love and intimacy. Fighting and tears when person A talks to person C about person B and person C then lets person B know, that is how they feel close. It is not only families, but communities. Clay Shirky’s description of a group being it’s own worst enemy describes the same patterns: identify an enemy inside or outside the group and then everyone comes together against the enemy. The enemy says the wrong thing, doesn’t worship the right god/desses, wears different clothes, looks different. And the group feels safer once the scapegoat has been killed, the guy has been burned. It would be nice if we could burn a ritual guy instead of torching each other.

The real anger is in the enabler. They control it by having the enablee express it. Then it is not “theirs”. They can feel superior to the enablee who is out of control. Sadly, the problem is only fixed temporarily and they will need their anger expressed again and again and again.

The cycle can be broken. It is a lot of work.

Blessings.

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Why care for addicts?

I posted this in November, 2015. I am reposting it.

_________________

Why care for addicts?

Children. If we do addiction medicine and help and treat addicts, we are helping children and their parents and our elderly patients’ children. We are helping families, and that is why I chose Family Practice as my specialty.

Stop thinking of addiction as the evil person who chooses to buy drugs instead of paying their bills. Instead, think of it as a disease where the drug takes over. Essentially, we have trouble with addicts because they lie about using drugs. But I think of it as the drug takes over: when the addict is out of control, the drug has control. The drug is not just lying to the doctor, the spouse, the parents, the family, the police: the drug is lying to the patient too.

The drug says: just a little. You feel so sick. You will feel so much better. Just a tiny bit and you can stop then. No one will know. You are smart. You can do it. You have control. You can just use a tiny bit, just today and then you can stop. They say they are helping you, but they aren’t. Look how horrible you feel! And you need to get the shopping done and you can’t because you are so sick…. just a little. I won’t hurt you. I am your best friend.

I think of drug and alcohol addiction as a loss of boundaries and a loss of control. I treat opiate overuse patients and I explain: you are here to be treated because you have lost your boundaries with this drug. Therefore it is my job to help you rebuild those boundaries. We both know that if the drug takes control, it will lie. So I have to do urine drug tests and hold you to your appointments and refuse to alter MY boundaries to help keep you safe. If the drug is taking over, I will have you come for more frequent visits. You have to keep your part of the contract: going to AA, to NA, to your treatment group, giving urine specimens. These things rebuild your internal boundaries. Meanwhile you and I and drug treatment are the external boundaries. If that fails, I will offer to help you go to inpatient treatment. Some people refuse and go back to the drug. I feel sad but I hope that they will have another chance. Some people die from the drug and are lost.

Addiction is a family illness. The loved one is controlled by the drug and lies. The family WANTS to believe their loved one and often the family β€œenables” by helping the loved one cover up the illness. Telling the boss that the loved one is sick, procuring them alcohol or giving them their pills, telling the children and the grandparents that everything is ok. Everything is NOT ok and the children are frightened. One parent behaves horribly when they are high or drunk and the other parent is anxious, distracted, stressed and denies the problem. Or BOTH are using and imagine if you are a child in that. Terror and confusion.

Children from addiction homes are more likely to be addicts themselves or marry addicts. They have grown up in confusing lonely dysfunction and exactly how are they supposed to learn to act β€œnormally” or to heal themselves? The parents may have covered well enough that the community tells them how wonderful their father was or how charming their mother was at the funeral. What does the adult child say to that, if they have memories of terror and horror? The children learn to numb the feelings in order to survive the household and they learn to keep their mouths shut: it’s safer. It is very hard to unlearn as an adult.

I have people with opiate overuse syndrome who come to see me with their children. I have drawings by children that have a doctor and a nurse and the words β€œheroes” underneath and β€œthank you”. I  have had a young pregnant patient thank me for doing a urine drug screen as routine early in pregnancy. β€œMy friend used meth the whole pregnancy and they never checked,” she said, β€œNow her baby is messed up.”

Addiction medicine is complicated because we think people should tell the truth. But it is a disease precisely because it’s the loss of control and loss of boundaries that cause the lying. We should be angry at the drug, not the person: love the person and help them change their behavior. We need to stop stigmatizing and demeaning addiction and help people. For them, for their families, for their children and for ourselves.

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werewolf

Time out word warning, in this poem. This poem is about discrimination. Substitute practically anything for werewolf…. disabled, bipolar, depressed, autistic, substance abuser. I am sick of discrimination. For human, substitute “normal”.

You know I’ve been a werewolf my whole life

Started in the womb
triggered by antibodies
to tuberculosis

And I am tired

of people telling me

I’m a werewolf.

Ok? I fucking know that.
I have known it since Kindergarten
where I arrived full of joy
ready to sing

and was shunned

we didn’t have a television

but I knew that wasn’t really it
I was different
I am different

and fuck you humans
different is ok.

I am a werewolf
and I am fucking proud
of all I have accomplished
in the teeth of humans hating me
and trying to shut me down
and shunning me
and reporting me
and doing everything short of shooting me
with real guns

I’ve been told to sit down
shut up
stop arguing
be nice
be good
go away
die
don’t read my writeups
don’t C! my work
don’t talk to me
stop making waves
been fired
been reported
been shunned
been alone

and fuck you humans

get ready
because I am middle aged now
for a werewolf
and I am ready

to be one all the timee

damn the torpedoes
full speed ahead
fuck you humans
for how you’ve treated me

I’ve turned the other cheek
for sixty years

and now
I
will
fight

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released like stars

I have had strep A sepsis and pneumonia twice. It was terrifying and I ended up having to take care of myself. I would be dead if I was not a physician.

Not to be named obscure website helped to sustain me, because it was a place I could go while I was alone, terrified and very very ill. The bout in 2014 took me out of clinic for six months and then I was barely able to work seeing half my usual number of patients. My local hospital refused to help me, but other people did. I am deeply deeply grateful to the people who did help me, including people on everything2.com that I have never met.

I wrote this in June 2014.

released like stars

________________

My sister used to tell me

β€œEverything2 is like a brain.

That’s what attracted me.

All the nodes, like neurons

Connected to each other more and more.”

Or something like that.


Isn’t it annoying?

Now that I’ve taken that memory out

Dusted it off

Embellished it

Who knows what she really said


Flashes of light now

And some where I blank out entirely

For just a moment

Only when I’ve eaten

I’m still avoiding carbs


Could be absence seizures

But she said seizures hurt

These do not hurt

And are accompanied by muscle twitches

Or muscles rolling gently across my frame


I am scared at first

Because I think they are neurons

Bursting into brain flame

And burning out

Brief candles


But I don’t think that’s right either

I think it is plaques

Deposits of antibody

Small pushpins in the wrong place

Being released like stars