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RLike nearly
half of
Americans
in his age
group,
Dimitri was
taking more
than five
medications
each day
to treat his
ailments
— 10, to
be exact.
scenario for a person with late-stage
Parkinson’s. He didn’t move or speak
much, was confused and incontinent,
and lately spent most of his time asleep.
Then I confirmed his other symptoms,
diagnoses and medications, and I asked
if there was anything else I should know.
“No,” she said. “I think that is
everything.”
It wasn’t much, but Svetlana gave
me all I needed to complete a standard
medical history. From here, I focused
the rest of the call on how we could help
him through what I thought were the final weeks
or months of his life.
A DIFFICULT CONVERSATION
I don’t usually discuss how a patient wants to die on
their first day in the nursing home. But Dimitri wasn’t
eating or moving much, and I needed to know his end-
of-life preferences. Svetlana appreciated the severity of
her father’s situation, so I hoped that she had a sense of
what treatments Dimitri would and would not want at
this stage of his life. Older people almost always have
more comfortable deaths when we stop drugs that are
no longer helping or are meant to prevent problems
they won’t live long enough to have.
As is often the case in families, regardless of back-
ground, Svetlana hadn’t talked to her father about his
death. So I moved to proxy questions: Had Dimitri
ever commented on the deaths of friends or family
members in ways, positive or negative, that could
guide us? Svetlana answered in a voice that was cooler
than it had been just moments earlier. “In Russia,
people die quickly. I don’t see how I can help with
these questions.”
She began thanking me for my call.
“Just one more question,” I said. I wanted to get a
sense of how quickly Dimitri was declining. I asked
what her father had been like two weeks ago, and
two months, and six months, and a year. As Svetlana
reached the middle of her answer, I stood up and
grabbed a pen.
CASCADE OF CLUES
After I hung up, Marina, who missed nothing on her
unit, appeared out of nowhere at my side.
“What?” she said.
“He was perfectly healthy a year ago. Mind, body,
everything. Six months ago, he was still walking and
talking and reading engineering journals.”
Parkinson’s is a slowly progressive chronic disease.
Except for certain rare strokes, it does not reach end
stage in a matter of months. A combina-
tion of drugs, though, can cause older
people to suddenly show symptoms of
Parkinson’s and dementia. And Dimitri’s
list of meds contained possible culprits.
I called Dimitri’s neighborhood phar-
macy to find out when he started taking
each of his medications. Bingo! I immedi-
ately stopped eight of his medications and
wrote for gradual elimination of the other
two. I also asked the nurses to check him
frequently over the next few days. I wanted
to know sooner rather than later if I was
wrong, and to make sure he remained comfortable.
By the end of the week, Dimitri could sit up. He
began talking — quietly at first, but each day his
voice became stronger and louder. He ate more and
moved better. I ordered physical therapy. His blood
pressure went up, and I started him on a medication,
though a different one than he’d had before. That
previous medication seemed to trigger the cascade
of side effects that left him bedbound, with erroneous
diagnoses of Parkinson’s and dementia.
His old blood pressure medication was a good one,
effective and inexpensive, but it can cause gout. So
when Dimitri’s right ankle swelled, instead of chang-
ing his hypertension drug, his doctor treated the gout
flare with a strong anti-inflammatory that worsened
Dimitri’s long-standing heartburn. His gastroen-
terologist then prescribed a medication that caused
Parkinson’s-like symptoms, prompting the mistaken
diagnosis. This triggered more prescriptions, and
more side effects, including hallucinations and uri-
nary problems, each of which was treated with more
medications that left Dimitri sedated and confused.
Every geriatrician I know has stories like this one.
Six weeks after his admission to the nursing home,
Dimitri was transferred to the assisted-living unit.
The first time I passed him in the downstairs hallway,
I didn’t recognize him. He wasn’t even using a cane.
Although he could have moved back home, it seemed
he’d found a new life that suited him well. He began
painting, was elected to the Residents Council and
made a new lady friend. Since he was still married,
this caused a small scandal, but Dimitri didn’t care.
When I left the nursing home five years later, he
remained healthy, active and happily coupled.^ D
Louise Aronson is a geriatrician in San Francisco and
author of Elderhood: Redefining Aging, Transforming
Medicine, and Reimagining Life (Bloomsbury, June 2019).
The cases described in Vital Signs are real, but names
and certain details have been changed.
VITAL SIGNS