Resistance to Care

Failure to Thrive

Worsening Judgement

Letters from Patients

Resistance to Care
An 87 year-old woman with gradually worsening dementia and stiffness has become more resistant to having her briefs changed. She has developed a painful red skin irritation in her groin area that compounds the problem. She grits her teeth, hits the caregivers and pulls her body up making it difficult to dress her or bathe her. Medications: Haldol, Ativan, Ambien, Imodium as needed

In this case the woman has become more stiff from the Haldol, which has not decreased her combativeness. Haldol is an antipsychotic – it lessens delusions, hallucinations and paranoia. Ativan, a tranquilizer chosen to combat anxiety or agitation, can also be disinhibiting — like a shot of vodka — and is not likely to make her calmer, but more confused and is also associated with an increased risk of falls. Similarly, the Ambien, a sleeping pill, might only work for 4 hours and can also cause more confusion. Immodium, for diarrhea, may further increase confusion and combativeness with dementia, and may also mask a serious problem from diarrhea.

This woman needs more gentle care cleansing in her groin area — it may be painful. Also she likely has a yeast rash that needs to be treated, and soiled briefs can worsen skin irritation. As far as which medications would successfully calm her, that is very individual and must be decided on a case-by-case basis. She was given Celexa, an antidepressant and was less combative.We also worked with her caregivers to explain what they were doing more slowly to her and to begin by massaging her arms, and gradually working down to changing her briefs.

Failure to Thrive
An 80 year old man with a history of avoiding doctors lived at home with a caregiver. He developed pneumonia and was admitted to the hospital. After being discharged from the hospital he was transferred to a nursing facility. After six months in the facility he was found to have iron deficiency anemia. The patient could say he understood that colon cancer might be a cause, but would not answer when asked if he would agree to have a colonoscopy to confirm this diagnosis.   The patient subsequently stopped eating. Medications: Iron, potassium, Motrin,

This man had several reasons to stop eating. First, the medications he was taking can irritate the stomach. The first step in devising a course of treatment was determining what, for this gentleman, were his goals of care. In other words, What makes life worth living?  His family at first wanted him admitted to the hospital, which terrified him. With further discussion, they learned that we could perform a diagnostic exam without moving him.

The patient stated that if cancer was discovered, he did not want any stomach surgery. He did not like doctors and did not want blood tests. Instead, we did a swallowing x-ray study and found that his esophagus did not contract, which made it impossible for him to eat solid food. He lived in comfort for the next 1 ½ years on a diet of ice cream and Ensure. Ice cream provides protein, calories and fluid, and will be eaten by almost every patient. He was not subjected to the fear and discomfort of hospital interventions he did not understand or other tests or procedures he did not want. When he grew much weaker, the family chose hospice support and he ended his days in comfort surrounded by his loved ones.

Worsening Judgement
An 83 year old woman, a retired nurse, lives alone and has become progressively weaker. She has difficulty getting food, because she no longer drives. She is suspicious of neighbors, having called the police 83 times in the last 2 months. She also had many police complaints filed against her by taxi drivers, bankers and pharmacists due to her abusive behavior. Many of the appliances in her home did not work. She refused to have help at home or to let her physician speak with her sons or her previous doctors. She claimed she would sue him. Medications:  Restoril, Wellbutrin and Ativan

Frontal temporal dementia can be the most challenging of cognitive declines. The person may know the date and current events, but their interpretation of events and their judgement can be severely flawed, and often gets them into trouble. It can be perplexing for the family exactly how to help their loved one, who often refuses help or does not acknowledge any difficulties.

In most cases, if a person has refused to let anyone speak to the doctor the best option is to gather the pertinent information from the caregivers, family, and police and to discuss the case with the local Adult Protective Services office. When there are health complications arising from a decline in judgment then further steps can be taken in compliance with HIPPA privacy rules.

In this case the patient’s medications contributed to the problem; Ativan can impair judgement and affect behavior, Wellbutrin can be overstimulating and make some people more irritable, and Restoril can also make those susceptible, more confused. Restoril, like Ativan, is addictive and this can cause more problems, or can precipitate delirium if stopped suddently,

When this patient fell and had several fractures, she entered the hospital and became delirious from the change in her Ativan use. The family, geriatrician and the eldercare attorney collaborated to address her unsafe living conditions and decision making capacity. It was determined by the court that she lacked sufficient judgment to live alone safely, and since she refused help at home she was transferred to a safe assisted living arrangement. She was tapered off the Ativan, Restoril and the Wellbutrin and given a gentle antidepressant and mood stabilizer. She tolerated care much better thereafter.

Letters from Patients
Dr. Landsverk has worked with literally hundreds of patients and families. Here are excerpts from letters written by some of them:

“It was terrific that you made a housecall on such short notice … but how you treated both of us mattered tremendously to me. You really listened to my mother; I could tell, when you repeated her situation and her wishes back to the medical ethicist you called on the phone, and I felt you really respected my mother as a person. You were prepared to take difficult practical steps … but I didn’t feel you were going to railroad me or my mother into a decision. You also didn’t strand me after the housecall … thank you for being the help that came.”

“I wanted to express to you again what a blessing you were to our family for making a house call to assess Mom the same day I called. May God richly reward you for your compassion.”

“Your orchestration of Norma's health care has been paramount in getting her in a safe environment. You have been so helpful in such a whirlwind situation. Andy and I both thank you.”

“Thank you for your efforts this evening regarding my mother. She really seemed to respond to your help and I greatly appreciated your candor and direct approach. You are a true professional and a delight to work with under such a difficult scenario. “

“Of all the doctors that had treated Mom on her medical odyssey, Dr. Landsverk was far and above the most outstanding. If only we had found her at the beginning of our mother’s illness, I have no doubt our mother and our whole family would have fared so much better... Dr. Landsverk approached my mother with utmost kindness and respect, talking directly to her (as opposed to me with my Mom as a nonentity). She was very non-threatening in her approach, letting my Mom get used to her gradually. (I often felt other doctors were rushed and preoccupied.)  As Dr. Landsverk took this time it was apparent she was assessing my Mom on a range of issues (memory, speech, hearing, appropriateness of response, movement ability etc. ) and she was letting my Mom assess her... She listened very carefully to what I was observing in my Mom’s behavior. She interfaced directly with the nurses, being sure that her instructions were clearly understood... Dr. Landsverk worked carefully with the drugs my mother was on, gradually weaning her off some altogether, reducing others and adding new, more appropriate ones. Dr. Landsverk gave my Mom a much higher quality of life. Depression lifted, she would engage much more readily, and her memory seemed more stable... Best of all her smile (which she was famous for) returned. Her strong will and sense of self were also back... Dr. Landsverk was always available by telephone. She returned messages promptly. If problems developed, she was available for unscheduled visits... Dr. Landsverk is a special doctor. She brought not only all of her expertise, but her wonderful down-to-earth personality, happy smile and nurturance to my mother. She addressed in my Mom the person, the soul inside, that was shrouded by illness and dementia. Like for us, I am sure she would be a godsend in helping any patient or family of the elderly navigate the confusing healthcare labyrinth.”