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Doctor's advice

I'm 82 years old and I'm self-sufficient. So far I have managed to do all the household activities and shopping without much help from others. For a number of months now I have found myself more and more often going out of breath. I have also noticed that my legs swell around the ankles. I get tired more easily. In fact the only disease I suffer from is hypertension. Are these symptoms of ageing? Is there any medication for that?

Getting tired easily and going out of breath, or what doctors call 'reduced effort tolerance' and 'dyspnea', are certainly not symptoms of ageing. What is more, if coupled with the swelling of lower limbs, they may be symptoms of a serious illness which is referred to as 'cardiac insufficiency' and which can be effectively treated. The most common cause of cardiac insufficiency in the European population is hypertension and coronary disease. You definitely need to see a doctor.

 

I'm 69. I'm a widower and I live on my own. My granddaughter, who is studying in Kraków, helps me. For many years I have been suffering from diabetes. I do not even remember since when. I have noticed recently that a callus on my foot has got larger and oozes, and the whole foot goes numb. My GP has said it is time to go on insulin. I'm terribly afraid of insulin. Is it really necessary?

It seems that in your case it is time to start insulin treatment and probably there is no other solution. In the treatment of diabetes there are certain situations that we, doctors, perceive as absolute indications for taking insulin. The so called 'diabetic foot' is one of them. Insulin treatment is not that bad but it requires much discipline in keeping the diet and self-measurement of glucose levels. In Kraków there are special education centres for diabetics, where experts will teach you how to use insulin correctly. In the treatment of diabetes you will be guided by your general practitioner. He or she will direct you to the appropriate clinic, which will coordinate your treatments.

 

(part of a patient interview) I live alone. I'm a widow. I have wonderful children and grandchildren, who would do anything for me. It was my daughter that has brought me here. But nothing seems to make me happy. I stay at home most of the time and tears just keep rolling down my face. I think about my late husband then. I do not want to make my children feel sorry but I just no longer want to live.

Very often sorrow, tears, thinking of painful memories, loss of enjoyment and interest in life or recurrent thoughts of death, are symptoms of an illness called depression. Prolonged grieving and sense of sorrow after the death of a loved one are not normal behaviour either. In all likelihood you are suffering from depression, but it can be effectively treated. It is a common thing that senior persons tend to not enjoy interaction with their children and grandchildren. Certainly you could benefit from contact with your peers, who would understand your worries and health problems. Depression is a very serious disease - its symptoms must not be underestimated, and in any case they must not be identified with the process of ageing. The patient's family have a particularly important role here, as only rarely do depression sufferers seek help on their own. If they do come to the doctor, it is typically to complain about memory or concentration problems. So if the family notice that an elderly person is often sad and weepy, has lost interest in the things he or she used to enjoy, has memory problems, says things like "life is not worth living", "I want to die", etc., they should seek doctor's help immediately. The doctor will make a diagnosis and prescribe treatment.

 

I'm 76 years old and mentally sound. I suffer from many diseases: I have had heart attack, I suffer from hypertension and pain in my joints. Many ailments and many drugs. Some from the cardiologist, some from the neurologist, others from my GP. I also take over-the-counter medicines. I'm beginning to feel confused about what I should take and when.

The problem you are describing is a very important one in geriatrics, the branch of medicine that focuses on the care of the elderly. We call it "comorbidity" or "polypharmacy", that is the presence of multiple diseases in a single patient and the necessity to use a large number of different pharmaceuticals to treat them.

It is essential that someone sorts it out, to speak colloquially, for you, and leaves only those medicines which are indispensable for your life and health, eliminating the ones whose efficacy has not been documented. It would be a good idea to ask the doctor for a clearly presented drug-taking schedule, specifying the medicines to be taken in the morning, at noon and in the evening. At pharmacies you can buy special pillboxes divided into little compartments that you can use to keep drugs to be taken at different times of the day. This makes it much easier to control what you are taking and when. You must remember that even those over-the-counter pharmaceuticals that are apparently 'innocent' may cause serious interactions (harmful effect) with the drugs that are indispensable for you.

 

How should I help an elderly person without making him feel infirm and decrepit?

As far as practicable, you should use the faculties, both intellectual and physical ones, of the elderly or ill person, and assist him rather than do everything, even the most basic activities of daily living, for him. It is a common mistake, usually made out of concern for a parent's or grandparent's well-being, that all activities connected with maintaining hygiene, grooming and feeding are done for such person by others. An elderly person must still feel needed, important and, as much as possible, independent. When he or she needs help, it is crucial that assistance is provided in a tactful and discrete manner, and that his or her other skills and preserved abilities are emphasised.

 

I take care of my grandmother, aged 85, who has terrible memory problems, is aggressive and mean, and has no appreciation for what I do. Noone helps me take care of her and I hardly manage myself, although I love my grandma very much and I wouldn't like to put her in a nursing home.

Taking care of an elderly person who suffers from memory impairment, behavioural disorders, agitation, aggression, combined with lack of criticism (the symptoms described suggest that the patient suffers from dementia) is difficult and often requires involvement of many people, including professionally trained ones. First of all, an attempt should be made to improve the patient's functioning by using medicines enhancing memory and concentration, and reducing behavioural disorders such as anger, agitation, aggression, and sleep disorders. However, drugs cannot be expected to solve all difficulties involved in taking care of the patient. The relatives must understand the nature of the problem, be aware that her behaviour is the effect of a disease rather than manifestation of her meanness or ill will.

The obligation to provide care to a dementia sufferer rests with his or her children (and this is not only a moral obligation but also a legal one). Maybe you should hold a family meeting and discuss the scope of duties of each member of the family. Obviously, this does not mean that you cannot take care of your grandma. But you have every right to expect strong and effective support from her closest relatives. You cannot be the only and indispensable carer - you must have time for rest and your own life. In the long term you could also consider a professional nursing home.

 

Where should a person with vascular dementia who has had another stroke be rehabilitated: at home or in hospital? Shouldn't hospital care be as long as possible?

A person with dementia should stay in hospital as long as such stay is necessary for medical reasons but definitely not for reasons related to nursing. Rehabilitation may be commenced in hospital - at a neurological or rehabilitation ward - and continued at home under supervision of a physiotherapist. For an elderly person suffering from dementia a stay in hospital has numerous negative aspects in addition to the positive ones, including exposure to intra-hospital infections that are difficult to cure, remaining immobilized in bed, compromised sense of safety, or emergence of behavioural disorders caused by the unfamiliar environment. As a result, when in hospital, the patient receives more sedatives, remains bed-bound for a long time, and may develop infections which pose an immediate threat to their life. A decision on discharging the patient from hospital is made by the doctor, who takes into account all aspects of the situation and chooses the solution that best serves the patient.

 

Are there any medicines for dementia which could stop an elderly person from escaping repeatedly from home and trying to return to her old, no longer existing flat?

Of course there are pharmaceuticals that repair behavioural disorders, reduce the psycho-motoric drive, and thus alleviate the constant urge to leave home. A specialist in dementia care (a neurologist, geriatrist, psychiatrist or general practitioner with a wealth of experience in treating the elderly) must select the appropriate dosage and type of medicine. Irrespective of that, it would be a good idea to equip the patient with identification, possibly in the form of an identity bracelet to be worn permanently on the patient's wrist, with a contact telephone number.

 

Are there any ways to control urine leakage in an elderly person with dementia? Is the use of a catheter or adult diapers the only solution?

Urinary and faecal incontinence is a permanent symptom in the later phases of dementia. Its treatment at that stage is very difficult, and in the most advanced phases of dementia even impossible. At the beginning the leakage occurs only occasionally but the problem progresses over time until the patient is not able to control their sphincter muscles at all. At the earlier stages, when the patient's cooperation is still possible, special exercises are recommended, including exercises strengthening the lower abdomen muscles, contracting and relaxing the sphincter muscles, or regular visits to the bathroom, for example every hour or two, regardless of whether the patient needs to urinate at that moment. It is recommended that smaller amounts of fluids be consumed in the evening, but without reducing the fluids intake during the day (a common mistake in taking care of a person suffering from urinary incontinence). An elderly patient should drink 1.5 - 2 litres of fluids every day. Older patients often do not feel the need to drink because of thirst centre dysfunction, and additionally they reduce the amount of liquids they consume because of the problems with urination control.

There are also ways to repair the dysfunction urologically (they are more effective if the reason for incontinence is other than dementia) and pharmacologically, but the type of treatment should be determined by a doctor on the basis of a full clinical picture. However, more often than not ultimately the use of diapers or pads is inevitable. On the other hand, the use of a catherer inserted into the bladder is strongly discouraged, as it poses the risk of repeated infections of the urinary tract that are difficult to cure.

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