Sunday, March 15, 2020


     We are having aging population. I have seen at times 3 patients with age greater than 90 years at one time in hospital. In spite of the problems that the patient and the relatives  and the society faces , almost every patient that I see wants to live to be 100.. I think I am seeing more  and more patients who are older  and have some medical issues that have become or will become problem . Many a times when I see patients who have chronic cough  and they  are advanced age  and other basic work up is negative  and usual treatments do not work and the cough continues, I tend to order swallow study to make sure they do not have aspiration , which means the the food particles or liquids go in wing pipe / lungs instead of food pipe . This causes cough and then leads to inflammation. This causes cough . Many a times swallow study comes back abnormal but not bad enough to stop eating, but I feeling is that one can do well 100 times  and then one needs only 1 episode that leads to the problem . Just like you can drive well without the accident for 100 days  and then you get in an accident. Some times the problem is bad  and the patients  are not willing to do feeding tube or make all liquids 'thick ' to help prevent aspiration..But today I am going to tell additional problem that we ALL are facing - medical persons  and patients  and the family and in tern the society.
     I have seen this 93 years old male for last 4 years . He had some cough and some shortness of breath . He had heart problem and had surgery and also had valve problem and was followed by cardiologist . he was active and did OK for 2 years or more . He had some fibrosis in lungs  and that was causing the cough and some shortness of breath. He stopped following me  and then after the gap of 10 months I saw him in hospital. He had developed dementia  and he had been moved to Memory Unit by family. He got sick an so he came to hospital. We did the work up and he had fibrosis and that seems to be stable on CT scan . He also had pneumonia  and he also had corona virus - but not the COVID 19. I knew that he must be aspiration as the age had advanced  and he also now had dementia. We treated the respiratory problem and he received antibiotics  and steroids  and also received bronchodialaters . He did well . His lungs improved  and he had not much cough and oxygen improved . I also did swallow study and he had aspiration . The speech therapist felt that if he could follow certain precautions ,he could eat certain way , he would not need feeding tube . The family had told me in advanced that they would never consider feeding tube. So they were happy to know that he can eat though with certain precautions. I was not too sure how much he could understand  and follow. Since he had MEDICALLY improved,, we started talking about discharging him. The memory unit did not feel he could go there as he was too weak  and we had started physical therapy . But he was not doing much and not following much of the instructions. The family wanted him to be in hospital till he got BETTER.But the medical problems were much better and he was ready. I was not sure that there was much physical therapy potential due to his dementia . So we were in bind . The dementia was not going to get much better and the physical therapy may or may not work The family was not ready for taking him home  and that would have been too much of a care. The physical therapy unit would be good , but how much could he do ?
      This situation is not uncommon and one does not have to be old .But we see this in older patient more often. I don't have answer for this socio-medical problem. 

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