Getting older, and better

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Care of the elderly, especially of those with asthma or chronic lung disease, is a much-neglected area of medicine. There are also unnecessary taboos which further complicate their lives. Dr. Sujeet Rajan discusses the issues critical for good geriatric care and explains the urgent need for organised palliative care in India.

Snehlata Chopra is 88 years old, has chronic asthma, acid-reflux, is a bit overweight, has an occasional irregular cardiac rhythm, cancer of the breast in the past, glaucoma in both eyes, and anxiety. She manages to move around her home without support, and occasionally steps out in a chauffeur-driven car for an outing. Two maids employed at home (one for cooking, and one for cleaning the house) have been instructed by her daughter to always keep an eye on her. She is very careful about all her medication, extremely sensitive to any changes in doses, and expresses concern whenever I prescribe anything new – believes she will react to it adversely.

I refrain from doing so.

But I requested her to use a walking stick last week while walking inside her (fairly large) living room, negotiating a couple of sofa sets and other furniture. She looked at me as though I was out of my mind. Smiling at her daughter, she said I wish there was a solution to my problems of reflux and breathlessness.

I persisted on the walking stick.

Her daughter changed the topic. “We have enough servants in the house, Dr. Rajan. Don’t ‘stress’ mummy on that now”.
I realised it was now futile. The walking stick was actually a stress for the mother. I didn’t want to add to her already ever-increasing stresses.

Why is the walking stick taboo?
While walking at home last week, Mrs. Chopra had a fall, fracturing her hip. She is likely to be laid up for at least the next 3 to 6 months. She is miserable. So is her family. There is also a 30% chance she will never be able to walk again.

Her daughter text messaged me last week, “Hi Dr, am still in hospital with mummy, hope she gets better soon, but there are so many problems now with her, cannot bear to see her suffer”.

Such situations are not uncommon in India, where using a walking stick seems to be a taboo for many elderly people. One lady (with chronic lung disease) discharged from the hospital two months ago, and advised by me to walk regularly with a physiotherapist’s help, returned for follow-up a week later on a wheel-chair. When I asked her what made her do that, she replied “I was too tired to walk today, but I walk regularly with the physiotherapist’s support at home”. I asked her why not use a walking stick? She smiled at her son who had accompanied her. Her son sheepishly replied that his mother was too embarrassed to use one. I immediately retorted that she had come to the clinic in a wheel-chair. Wasn’t that worse? He looked at his mother and duplicated what I said in Gujarati (which I am not fluent with). She mumbled something back. He looked at me with a half-smile and said “That’s ok with her”.

Atul Gawande in his masterpiece book, Being Mortal, has highlighted how doctors have completely failed in looking after elderly patients well, or may I add, well enough. We seem to be using technology well to prolong lives and increase longevity, but fail to understand situations where it’s not technology, but common sense and simple solutions that will give many of our elderly a much better quality of life, in their final years.

Keeping an elderly sick patient (with end-stage lung disease) comfortable
A 74-year-old lady, Sheela Vora, with chronic end-stage lung disease on home oxygen for the past two years presented to our hospital emergency service. Her husband was counselled by the earlier doctor she had seen that should she get worse, he would not advise invasive ventilation. (Invasive ventilation refers to putting a tube down the patient’s throat into the windpipe, and attaching that tube to a ventilator. It is very uncomfortable for a conscious patient, making it almost impossible to talk, or eat food the normal way).

Our hospital emergency response team seeing her extremely uncomfortable and gasping for breath, placed the tube into her windpipe immediately and transferred her to ICU (Intensive Care Unit) for ventilation. Her husband just kept saying, “Please make her comfortable. She has been suffering so much…” He (and his wife) were at the mercy of the hospital emergency response team.

Media perception of chronic lung disease
In 2003, I was privileged to speak to, and hear Bartolome Celli, a respiratory physician in Boston, speak on chronic obstructive pulmonary disease (COPD) to doctors in Mumbai. Bart is originally from Venezuela, and is a lively person full of energy and wit. A press conference was organised before he delivered his talk on COPD. Here’s how it went:
Journalist – “Professor Celli, what is COPD?”
Professor Celli – “Young man, do you know what SARS stands for?” (the Hong Kong epidemic of SARS was just underway having killed close to 300 people)
Journalists (almost in chorus) – “Severe Acute Respiratory Syndrome”
Professor Celli – “Well done. Is anyone here aware about how many people have died of SARS?”
All 5 journalists knew the exact figure (plus or minus 3).
Professor Celli – “Wonderful guys, your knowledge on SARS is phenomenal to say the least. You know something – COPD kills about 50,000 Americans every year, and possibly 500,000 Indians every year. And you guys don’t even know what it stands for! You are the guys possibly responsible for these COPD deaths. We’re just wasting our time here. Let’s end this interview”. Bart told me later that this was the story of chronic lung disease – poor awareness by patients, poor management by doctors, poor communication with resultant disastrous physical, emotional and financial consequences for the patient and society at large.

When I saw her a few hours later in the ICU, I asked him why he brought her to us for invasive ventilation. She was very sick at home on oxygen, she was unlikely to survive this episode with any reasonable quality of life, and the family was middle-class – this ICU stay was going to cost a bomb.

What the husband then said was pertinent – “Our doctor whom we trust had surely told us not to ever put Sheela on a ventilator when she gets worse”…..but then his voice trailed off. “But he didn’t tell us what exactly we need to do, should she get worse…….so we brought her here”.

Urgently needed – palliative care!
I know of just one palliative care specialist currently practising in Mumbai city, and we can’t wait for more. As a physician community we need to get our act together on better palliative care, especially for our elderly sick patients.

Palliative care seems (for many) to be synonymous with cancer, but it is far from that. In a small district in Kerala called Mallappuram, some of the finest palliative care initiatives can be seen, done quietly and efficiently by a strong local community effort. In their definition, palliative care is all about keeping the patient comfortable. It could be just providing food to a patient with advanced disease who is unable to purchase it on his own, or providing an air-bed to a chronically bed-ridden patient to prevent bedsores and subsequent infection.

Keep yourself well as you age
Whether its walking sticks, palliative care or just understanding the problems of chronic lung disease, there are many other ways to improve the quality of life when you are old:

To give some more examples:

  • We can’t stop the ageing of the human body and mind, but we can most certainly make it more manageable. Good foot care is extremely important in elderly people. Unclipped toe nails, swelling and poor hygiene can all promote foot infections – increase the risk of a fall.
  • Speak to your doctor about avoiding medication (like a diuretic for blood pressure) that is likely to cause dehydration.
  • Eat slowly. If you are very old, you will tend to occasionally choke more easily on food. Swallow with the head slightly bent downwards. It helps to reduce aspiration.
  • Aspiration is a common cause of pneumonia in very elderly patients. If you are very old, (and especially if you tend to have reflux problems), sleep with the head end of the bed slightly elevated, ideally to 30 degrees. Eat light and early dinners.
  • Vaccinate yourself after the age of 65 years against pneumonia. Remember, after 65, your body’s immunity takes a dip, and your risk of getting hospitalised or dying of pneumonia increases multiple-fold.
  • Importantly, also speak to your doctor about getting vaccinated against influenza every year. In Mumbai the peak flu season is from May to August, so the best time to take the flu shot (either injection in the arm, or by nasal spray) is in April. In Delhi which follows a continental climate, September may be more appropriate.
  • If you have access to a herpes zoster vaccine (not yet available in India), I would strongly recommend speaking to your doctor about that vaccine as well (post age 50).
  • Be as physically active as possible – if necessary, with a walking stick – studies have shown increased physical activity to correlate with an improved and longer quality of life. Increased physical activity also reduces acid reflux.
  • Ask a professional to see how he can make your home more safe from falls. Grab bars in the bathrooms and in lifts, go a long way. Even if you take adequate calcium and all kinds of medication for osteoporosis, remember if you fall, you are still very likely to fracture.
  • If you are very old, check if someone can look up on you once in a while – rather than employ a full-time nurse. It can go a long way in having a companion and someone you can talk to, and also having some connection to the outside world.
  • If you are anxious, depressed or angry, get a pscyhologist or psychiatry consult. You may not need many drugs, and sometimes just talking about your fears and concerns can help.
  • Always ask your doctor questions. Make a note of them in advance to save time. Remember, as an old patient, it may take you more time to get into the doctor’s clinic, and also leave the room. Inform the secretary in advance that you may need this extra time, and your appointment will be far more valuable to you.

  • T-D-Rajan

    Dr. Sujeet Rajan

    The writer is a Respiratory Physician at Bombay and Bhatia Hospitals in Mumbai.

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