Hospital Unit Eases Turmoil for Elderly With Dementia

Derold Biggerstaff was sitting at his desk in his Playa del Rey home when his wife, Ardnell, teetered into the room.

She wore a high-heeled pump on one foot, a running shoe on the other.

“My shoes are lopsided,” the distressed woman told her husband of 51 years. Biggerstaff explained about her mismatched shoes. “What should I do about it?” she asked.

The Biggerstaffs, who are in their early 70s, are among the millions of elderly Americans dealing with the wrenching reality of Alzheimer’s disease and other disorders that produce cognitive impairment or dementia.

Helped by Program

Although there is no cure for Alzheimer’s, the Biggerstaffs are being helped by an unusual program at Century City Hospital that offers them both comprehensive assessment and, if necessary, coordinated treatment of Ardnell Biggerstaff’s medical, psychological and functional condition, as well as psychological and practical support for her husband--all at one location.

Lynne Morishita, the nurse practitioner who heads the hospital’s Center for Geriatric Health, said the program is designed so that even people who are confused can take advantage of it.

Instead of making and keeping track of appointments with a host of different doctors, social workers and others, an elderly person who wants to be evaluated at the hospital only needs to make a single appointment. If necessary, the hospital will provide transportation--usually in a van that can accommodate wheelchairs.

About 10 elderly people with dementia are evaluated each week in the Alzheimer’s Disease Institute, which is part of the Center for Geriatric Health, Morishita said. The cost varies according to the tests and procedures done (the center, which also evaluates elderly people who don’t suffer dementia, accepts Medicare).

While being assessed, dementia patients spend one whole day at what the staff calls its geriatric day hospital, a suite of examination, conference and other rooms next to the hospital’s in-patient geriatric ward.

Although they don’t spend the night, they are assigned a regular hospital room with a private bath. The main reason for that, Morishita said, is to ensure their privacy. “A lot of the things we need to talk to them about are very delicate,” she said, noting that many patients are embarrassed by their memory loss or other symptoms of cognitive impairment. They may also be sensitive about such symptoms as the inability to control urination.

Determined by Team

Throughout the day, patients are seen by a team of physicians, including a psychiatrist, nurses, social workers and others with geriatrics training. Patients’ condition, their emotional and intellectual state and their need for speech therapy or other rehabilitation are determined by the team. Any tests needed, except for X-rays, are done in the geriatric day hospital. Patients are escorted to X-ray sessions by hospital staff.

One advantage is that the schedule is flexible--important when dealing with people who may have enormous difficulty expressing themselves, may be irascible or may simply tire easily, Morishita said. Instead of starting right off with a medical history, “we’ll have the social worker go first if the person is resistant,” she explained.

Because the patient is there the entire day, the staff is able to observe how well the person functions. Is the patient able to use the bathroom? Is he or she angry or withdrawn? Does the patient try to wander away? What kind of vocabulary does he or she use? During lunch, is the patient able to feed himself or herself?

An evaluation of how well the individual actually functions is as important, in its own way, as the diagnosis of any disease that may be present. “What we are most concerned about is quality of life,” Morishita said.

Dr. Robert T. Wang, whose specialty is geriatric medicine, said even excellent physicians who lack special training may fail to identify the problems of elderly patients.

Other Diagnoses

“They are very good at treating disease, but they may not be very good at seeing the patient as a whole and what the person needs to function more efficiently,” Wang said.

Often, he noted, people who come in for dementia have already been told they have Alzheimer’s when they actually have some other disorder. Although Alzheimer’s is the most common cause of dementia in the elderly, affecting between 5% and 10% of all those over 65, Wang said he and his colleagues see at least as much stroke-related disease among their confused or otherwise intellectually impaired patients.

Alzheimer’s can really only be diagnosed by a microscopic analysis of brain tissue, usually only done during an autopsy, Wang explained. Although Alzheimer’s disease is progressive and incurable, some other forms of dementia are treatable.

Dr. David Trader, the program’s geriatric psychiatrist, said about half the elderly people he sees suffer from depression or some other treatable psychiatric disorder. Prescription drugs may also cause dementia-like symptoms, especially sleep medications and sedative-hypnotic drugs such as Valium.

The staff is not yet convinced, for instance, that Ardnell Biggerstaff has Alzheimer’s. Although she shows signs of confusion and memory loss, she surprised everyone when she was asked if she had seen anything interesting recently on TV. She answered, yes, that she had been disturbed by the murder of young actress Rebecca Schaeffer, whose name she recalled.

Whenever possible, the staff likes to see the patients’ families. Trader said the team often asks relatives to corroborate information supplied by the patient, who may have lost the ability to describe his or her problems. Moreover, families themselves are often in need of psychological support dealing with such painful issues as fears that they too will eventually develop Alzheimer’s.

Takes Toll on Families

Dementia takes its toll on the whole family, the team agreed. Besides listening to family members’ concerns, “we try to help the family adjust their expectations,” Morishita said.

Trader said he has observed adult children of patients with dementia “being nicer to their own children,” apparently because they realize that some day they too may be disabled and dependent.

Sherrie Ellman is the team’s gerontologist--someone, in her own words, “who has learned to look at the world through the eyes of the older person.”

Ellman, who often develops a relationship with patients and their families, helps obtain case workers for patients who need them, helps the families develop long-term care plans and assists with such painful decisions as whether or not to care for the ill person at home.

“Every situation is different,” Ellman said, echoing Tolstoy’s observation that every unhappy family is unhappy in its own way. The gerontologist routinely answers families’ questions about how to protect patients’ assets. She also arranges for legal advice from volunteer attorneys.

At the end of the day, the evaluation team meets to share their findings and make recommendations.

Staff Isn’t Depressed

Surprisingly, the team doesn’t find it depressing to work with patients who are often not going to get better. Most medicine is like that, Wang said.

“Medicine in general doesn’t cure,” the doctor said. “It manages. It tries to prevent further deterioration.” Small improvements in the patient’s comfort or mobility or ability to communicate can be major triumphs.

“By and large,” Trader added, “we can make changes in people’s lives.”

Although Ardnell Biggerstaff still spends much of her time staring off into space, her husband is very glad they found their way to the program. “You feel kind of alone in these situations,” he said. “I don’t feel so alone about it any more.”