Medical Teamwork Aids the Aged

It was a series of small changes that sounded the alarm.

The 82-year-old widow, always a meticulous housekeeper, began to let her apartment go. There were signs that she probably wasn’t eating well or taking her medicine as prescribed.

Even more worrisome was the fact that she called her daughter every night and spoke at length about how frightened she became in the evening and how lonely she was.

Help From Specialists

The daughter, fearful that the time had come to put her mother in a rest home, sought help from a team of geriatric specialists trained to evaluate the needs of the aged.

The four-member health evaluation and resource team operates under the auspices of CARING Inc., a geriatric research subsidiary of California Lutheran Homes of Alhambra, a nonprofit corporation that operates 10 facilities serving more than 1,000 elderly residents in Southern California.

A comprehensive medical and social assessment of the woman led the specialists to conclude that contrary to her daughter’s fears, the widow should continue to live alone, providing some minor changes were made.

The team recommended that her phone be equipped with an automatic dialing device so she could reach her daughter easily. She was also urged to install brighter lights in her apartment and join a senior citizens’ club for companionship.

Case Not Unusual

According to Dr. Arthur Schwartz, a clinical geropsychologist and director of the team, the widow’s case is not unusual.

“Her being frightened at night is common among the elderly when they see shadows as night falls,” he said. “This is called the sundown syndrome. That is why she phoned her daughter in the evening.”

And her social history revealed a lifelong distaste for housework, which she had done dutifully for years because she grew up in a generation that expected it, Schwartz said. After she started living alone, she belatedly became a liberated woman, he said.

There are times when the team, which also includes a geriatric physician, a nurse and a social worker, recommends that the patient be placed in a care facility.

For example, Mrs. Robert Picha, 63, of Pasadena, was convinced before she sought help from the team that her 90-year-old mother, who had lived with her and her husband for several years, would soon have to go into a retirement home.

Worrisome Changes

But she was worried about changes in both her behavior and her health and sought help in understanding them.

“My mother lived with my husband and me for 20 years and she was productive, alert and enjoyed life,” Picha said.

“But last summer she had two operations for a burst appendix, and we were caring for her at home with the help of nurses. She had been heavily medicated, and she wasn’t alert anymore.

“She wanted to dominate the household, and our whole life style was revolving around her. And she had an intense fear of being alone. It was a time of worry and stress for us.”

She said her mother’s personality had changed, and she was concerned about the effect of medication on her mental state.

Picha said the team helped her understand her mother’s personality change and the fact that it is not unusual for older people to become self-centered.

Concerned About Parents

Schwartz said many of the people the team sees are adult children who have become overly concerned about elderly parents and sometimes make hasty decisions on housing arrangements, based more on intuition than fact.

“We spend 75% of our time dealing with anxieties children have,” Schwartz said. “We assess the whole family because more than 80% of services provided to the elderly are provided by families.

“But because the children tend to become overly concerned, some of the elderly want to get their children off their backs. So we talk to the elderly person before we talk to the family.

“Most of the elderly don’t want to live with their children because they want to maintain their autonomy and freedom of choice. So if they no longer can live alone, a retirement community or board-and-care home is often a better choice.”

The team, organized 15 months ago, sees about four patients a month and spends about five hours on the assessment and report on each. Although it may recommend that a patient be placed in a care facility, it is not involved in the choice of the facility or the actual placement.

The basic fee, covered by Medicare, is $175. A physical exam is conducted separately and usually costs about $150.

Only Two Other Centers

Schwartz said the assessment center is unusual because of its comprehensive evaluation of all aspects of the person. He said only two other centers in the county--at Rancho Los Amigos Hospital in Downey and Long Beach Community Hospital--offer similar programs.

The Alhambra center, at 2312 S. Fremont Ave., does not impose geographic limits on patients but usually draws people from the West San Gabriel Valley because house calls are an integral part of the program.

“The hardest part is developing a referral network,” Schwartz said. “Mostly we are contacted by families who have heard of us, but we also contact social workers in hospitals and managers of federally subsidized senior citizen housing.”

Schwartz said 80% of the elderly seen by the team are women in their early 80s.

And often, he said, people such as the Pichas need information more than they need a specific recommendation.

After Mood Changes

The evaluation team is generally called in after children notice changes in mood and behavior. A parent may have trouble remembering things or become confused or disoriented. He or she may exercise poor judgment or have difficulty coping with daily life. Another common sign is depression, Schwartz said.

“First they go to their doctor,” he said, “but if he doesn’t find an immediate physical problem, he either tells the family he doesn’t know what is wrong or that the patient probably has Alzheimer’s disease, and that is just a guess. Often people are labeled Alzheimer’s when the problem is only depression because both disorders can cause memory loss.

“Our philosophy is that we can probably resolve the problem if we have a fix on what is happening.”

The first step, he said, is to arrange for a thorough physical exam.

“We can’t assume the mind is going when it might be a medical problem,” Schwartz said. “For example, a thyroid imbalance can make a person act senile.”

The second step is to take a thorough social history, examining personality type, education and life style. This is done during a home visit because, Schwartz said, “people behave differently in their own home. They are more relaxed because they are on their own turf, and we have a chance to see how they live. We also want to meet the family so we can see their behavior patterns toward the older person.”

Next comes a neuropsychological exam that tests orientation, memory and judgment.

“We look for physiological and psychological explanations for the person’s behavior to determine why it is happening,” Schwartz said.

After the data is gathered, the team writes a report listing recommendations. “These might include finding alternative living arrangements, physical treatment, counseling, or maybe doing nothing,” Schwartz said.