Caitlin Biedron: Multidisciplinary Teams BACK

Published by AFAR

As an MSTAR scholar working at Detroit Medical Center, I have had the opportunity to shadow geriatric fellows and attending physicians during their morning rounds this summer. This first-hand exposure to geriatric medicine has provided me with a much better understanding of the difficulties facing elderly patients, as well as the multidisciplinary approach that is needed to effectively address them. The following three examples highlight some of these complex issues, including functional status, delirium and dementia, and elder abuse.

While rounding in the Acute Care for Elders (ACE) unit at Detroit Receiving Hospital, I saw an elderly patient that was being assisted by a physical therapist and a nurse, as they attempted to have him walk a short distance in an effort to reduce the loss of function and mobility that often occurs while patients are bedridden in the hospital. Unfortunately the patient experienced orthostatic hypotension while in the hallway, and another nurse had to rush to get a chair, as the patient nearly collapsed on the floor. Fortunately a fall was averted, but the combination of factors facing elderly patients was clearly illustrated by this particular situation. While encouraging exercise and physical rehabilitation for patients is crucial (as functional status – and particularly disability in performing ADLs - is the strongest predictor of perceived quality of life), their ability to perform such tasks must also be re-evaluated on a frequent basis to ensure that falls and injuries are avoided. However, reaching this proper balance can be difficult, even when physical therapists are assisting with the patient’s recovery.

During morning rounds we visited another patient, who had been fairly responsive earlier in the day, and able to answer most questions and appeared fairly well-oriented to time and place. However, when the geriatric team visited this patient later in the morning, she began describing visions of smoke coming from the wall and other vivid images. Furthermore, she had great difficulty answering simple questions about where she was, who assisted her at home, and what her daily routine consisted of without delving into a detailed account of an unrelated event. The attending physician suspected that the patient was experiencing delirium because of the sudden onset. But when he asked her to repeat back a sequence of numbers, she was able to do so fairly well, showing that she could remain attentive and focused, which is not usually observed in a patient with delirium. Therefore, it was decided that a psychiatric consultation was needed, in order to determine if this was a case of delirium (in which case it may be necessary to determine whether it was being caused by an infection) or dementia (in which case certain medications would need to be prescribed and her discharge instructions/destination may be very different). This example once again illustrates the importance of a multi-disciplinary team and approach to geriatric care.

Another situation that was encountered with many patients was their lack of control over banking and financial issues, with the potential for elder abuse to occur. In two cases, elderly patients explained how either a relative or friend was picking up their social security checks, and paying the rent and other bills for them after depositing the check. However, neither patient would likely have the capacity to reliably calculate the exact amount that should remain after all of the bills were accounted for, and it was possible that not all of the remaining funds were being returned to the patient. The attending physician on call mentioned his concerns about both situations, and was especially worried about a patient who had a niece and nephew living with him, who could have been covering their living expenses at his expense. Although these were merely observations, the attending physician seemed very concerned about the situation. I am not sure how he planned to proceed, but his mention of elder abuse was surprising to me, and made me look at the situation much differently than I would have otherwise.

Caitlin Biedron
Wayne State University School of Medicine

"Diary of an MSTAR Student" follows scholars in the 2011 Medical Student Training in Aging Research (MSTAR) Program, highlighting their summer experiences. As they continue their path of research, training and clinical practice, read their daily thoughts at www.afar.org/mstarblog. New diary entries are posted every day, so check back soon.