Falling into Open Arms

It seems the patient needs little provocation to fall. He fell three times on Labor Day and twice this past weekend. The wife hesitates to let him use a walker. She fears the tip- toeing will escalate with wheels in front of him; the increased velocity will drive him into a more traumatic accident. Occasionally he'll use a cane to get around, though mostly he just loses them, his wife relates.

Six months ago the patient's blood pressure was dangerously low. He appeared today wearing compressive socks, a former suggestion they implemented. The spouse relays they are focusing on adding salt to the diet, and she's concerned about the thirty pounds he has lost since January. She wonders whether the action of sinemet varies with weight and the doctor shakes his head no, as he asks the patient to copy his movements with his own hands.

The doctor opens the left palm of his hand, with the right he pats the palm then flips the hand over and pats with the back of the right hand. Quickly he flips the right hand down and over, down and over onto the left palm. The patient extends his left palm as well, and with the right he makes a downward chop motion. The doctor asks whether he sees a difference in what their hands are doing. The patient concedes the doctor is doing something different and amends the chopping motion with a slap. The new action resembles slightly more of what the doctor is performing.

'There's an apraxia here.. It’s indicative of problems with thought..'

The wife comments she has begun to shave her husband's face. 'He's losing independent function…'

In a chair opposite her husband, the wife in a shirt of pale pink exhales and shrinks into herself, apologizing as an emotional wave passes and she sobs into her clenched hand. Wanting an unbiased opinion, she sought the advice of a social worker at the VA who informed her there are 2 total care nursing homes in Hernando County, and three more in West Pasco. The patient is considered 70% disabled, so the VA system should pick up the entire bill.

Frustration in her voice, the wife related the patient was into everything. Drawers, cabinets, closets; he turns the contents out, inspecting it all, reading the smallest print on a shredded discarded napkin. It's hard when you are the only one making all the decisions, she admits. She recalls seeing her husband standing in front of the chest of drawers, then abruptly going down and she was running to catch him. The force of his body hit her and they both fell on the floor.

The doctor faces her and tells her she must guard her own health; consider taking antidepressants as well, because they can help, even though she has appropriate reasons to feel as she does. The doctor leans back in his chair. Two things I can suggest, he holds his thumb and index finger erect. Physical therapy may help with gait and balance, though he will not learn anything new, and will retain little. Seroquel, at night will dampen the hallucinations, paranoia and delusions. During the day a smaller dose will diminish odd behaviors. As they leave the room the wife takes her husband by the hand, leading him slowly with his shuffling steps.