Clinical Geriatrics

Case Presentation
Mr. P is an 87-year-old man who has had dementia of the Alzheimer’s type for more than ten years. He has lived with his daughter, Mrs. S, and her husband for the past seven years since the death of his wife. Mrs. S brings him to his primary care physician to ask if anything can be done to help him.

Mr. P requires assistance with bathing, dressing, and meals. He can eat foods such as sandwiches with his hands but can no longer hold utensils and must be hand-fed in order to consume enough food. He has been incontinent of bladder and bowel functions for the past three years and often takes off his adult diapers. Mr. P calls his daughter by his wife’s name, and Mrs. S feels that he doesn’t really recognize her or her husband. He speaks only a few words and often repeats the same word over and over again when people speak to him. Mrs. S has hired a private aide to help her provide care for her father, as he does not like to take a shower. He has difficulty transferring into the bathroom and needs a wheelchair to travel more than a few blocks from home.

Mrs. S worries that her father sleeps more than 12 hours a day and no longer appears to react to her, her children, or her grandchildren. He used to enjoy listening to jazz music and would smile and move around. Now, he no longer seems to appreciate that the music is playing. Mrs. S tries to keep Mr. P active, but he often sleeps through family visits, movies, music, and her attempts to read or talk to him.

Mr. P has a history of hypertension, coronary artery disease, congestive heart failure, hyperlipidemia, benign prostatic hypertrophy, and frequent urinary tract infections. His current medications include metoprolol 50 mg twice daily, lisinopril 10 mg daily, aspirin 81 mg daily, furosemide 40 mg daily, simvastatin 40 mg daily, and tamsulosin 0.4 mg daily. He also takes memantine 10 mg twice daily for dementia. Mrs. S reports that her father has difficulty swallowing pills, and even when she crushes the medications he only takes about half of them.

Mrs. S worries that her father is declining and asks if anything can be done to make him more animated. She promised her mother that she would never put her father in a nursing home, but now she wonders if he needs more care than she can provide. Mrs. S asks the doctor for advice about what to do for Mr. P in his severely impaired state.

Discussion
Erikson¹ described the major crisis of late-life as “integrity versus despair.” Helping an older adult maintain integrity throughout the process of aging is a significant aspect of geriatric care. Dementia adds a new dimension to the task of maintaining integrity during a period of tremendous loss. Alzheimer’s disease (AD) is progressive in nature, with a gradual decline in all aspects of memory and function. For those patients who live longer, total dependence and loss of even the ability to recognize loved ones will result^2-4 (Table I).

Dementia has a major impact on society. The costs of caring for persons with dementia exceed $100 billion per year in the United States alone, and that amount does not include the formidable costs of informal care provided by family members and loved ones.^2,4 The emotional toll and burden of caring for a relative with dementia is immense. This includes emotional distress, economic burden, lost work time, and strain related to balancing the needs of child care and caregiving for the older adult.⁴

Families, and women in particular, provide 70-80% of care for frail older adults, with repercussions on the caregivers’ life and health.^2,4 Primary caregivers are often spouses who are elderly and have medical problems themselves. Daughters frequently step in when spouses are not present.⁴ Caregivers must reconcile the demands of different spheres of life: personal; family; social; paid employment; and caring.