Geriatric Care Manager: K. Paggi

Just When You Thought There Was No One to Help…Part 1 of 2

February 11th, 2008
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Old Hands

I first met Hank* 4 months after his heart attack. He was in his mid-seventies, living in a horrible nursing home: the kind with a foul smell, where two beds crowd one small room, and there are patients crying for help. Hank was on oxygen, tied to his bed, and had a permanent indwelling catheter. He was unshaven and dressed in a hospital gown. Hank was largely ignored by the staff because he was angry, combative, and had been known to connect a fist or a foot to aides and nurses.

I was hired by Arlene*, his power of attorney, and girlfriend of almost 30 years. He had only one family member, a son with whom he had a strained relationship. Friends visited occasionally but rarely got much of a response from him. Arlene’s job required her to be out of town frequently.

In late December (before I met him), Hank had been dressing for a party when he began having chest pains. He smoked and drank heavily, and prior to the heart attack, Hank had been diagnosed with chronic pulmonary disease, acid reflux, prostate enlargement and a mild tremor. He had seen his primary physician just three weeks before the attack, and aside from these conditions (which did not drastically affect his quality of life), he was given a relatively clean bill of health. Despite that, on that night in December, Hank was rushed to the hospital and had bypass surgery. He never went home.

Following bypass surgery Hank refused to eat, so a feeding tube was installed. He had a urinary infection; a catheter was placed. He was discharged to rehab, where he assaulted the staff and refused to cooperate. He fell multiple times and was re-hospitalized many times. In April, he was discharged into the nursing home where I met him.

As we talked I realized that Hank the person—not the combative patient—was still “in there” somewhere. He scored relatively high on the cognitive test, and had a high score on the test for depression. I thought that if Hank could be moved into a better nursing home, his depression would lift and allow his cognition to improve.

I reported my findings to Arlene and we discussed his financial picture. Hank’s successful career had allowed him and Arlene to travel all over the world; he had two luxury cars and a beautiful home. His major investment had matured just before his heart attack. To avoid a huge tax bill, he put everything into an irrevocable trust, keeping only a limited amount of money in his savings for retirement income. There was plenty for him to live well as long as he was healthy, but it certainly was not enough to pay for nursing home care. I talked to several lawyers about breaking the trust and to financial planners about how to finance quality nursing home care for Hank.

Within days of our first meeting, Hank was hospitalized with an electrolyte imbalance. During this 6-day hospital stay, Hank was kept in restraints plus a vest posy, apparently to prevent him from pulling out the IVs. I seized the opportunity to have him discharged into a good nursing home. The day he was discharged into this good facility, the nurses there found a long, deep wound on his forearm, and sent him back to the hospital. This wound was not mentioned in any of the hospital paperwork, and no one was able to tell us what had caused it.

During this stay in the hospital Hank was restrained again. I battled with the staff, requested that he be untied while I was there, and repeatedly asked for physical therapy to get him out of bed. He was discharged this time into the rehab unit of the good facility. Little by little, Hank was able to transfer himself into a wheelchair, and he began to allow the staff to shower and dress him without fighting with them. He sometimes came out of his room for meals. He knew me by this time, and called me “a pain in the ass,” which I absolutely was. I badgered him almost daily to get up, get dressed, attend activities, talk to me about his life and his friends, and to be nice to the nurses. I hired a companion to visit daily and insist that Hank shave, brush his teeth, and cooperate with physical therapy.

Even though I am not medically trained, I recognize medications given to older adults for chronic illnesses. Hank was taking Sinemet for Parkinson’s disease, as well as several mood-altering medications. I arranged an appointment with a neurologist who specialized in neuro-behavior and dementia. She confirmed that he did not have Parkinson’s and stopped the Sinemet and the mood stabilizers, and increased his anti-depressant. Her diagnosis was a delirium due to the infection in his arm. The neurologist later started Hank on a cognitive-enhancing drug. He was getting better!

Read Just When You Thought There Was No One to Help...Part 2 of 2

*Names have been changed.

Posted in Caregiver Burnout, Caregiver Support, Essential Resources, Geriatric Care Management, Geriatric Care Management: Kay Paggi

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2 Responses to “Just When You Thought There Was No One to Help…Part 1 of 2”
  1. Corinna Says:

    So many people have little idea what a GCM can go through in a typical day and just how much of it can be being called a “pain in the ass” by the people you are trying to help. It sounds like “Hank” is just like one of my clients who is begrudgingly ok with me being around all the time. Look forward to the next posting, Kay!

  2. Kay Paggi Says:

    You are a care manager, I can tell–and yes, sometimes I feel like a professional nag!

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