Making a Tough Call : Psychiatrist Must Decide When Freedom Is Too Much for Alzheimer's Victims

TIMES STAFF WRITER

Few people would complain if their doctor made a house call. But when Roland Jacobs shows up on their doorstep, patients may run the other way.

Jacobs, an owlish, 37-year-old, motorcycle-riding psychiatrist, runs what may be the nation's only service specializing in making house calls on Alzheimer's disease patients.

Families who fear that their elderly loved ones can no longer take care of themselves call this bearded biker with the kindly, low-key manner. His arrival is not necessarily welcomed by the people he visits because he has the authority to order people suffering from mental problems to be taken from their homes and locked up. A 76-year-old woman was strapped into a gurney on a recent morning and placed in an ambulance, all the while screaming, "Help! Help!"

That encounter in North Hollywood revealed the painful side of Jacobs' work as the administrator of a program known as Eldereach at Valley Hospital Medical Center in Van Nuys. When he makes a house call, Jacobs is an arbiter of freedom, deciding who is fit to continue living on his or her own, and who must lose that right. He describes it as a "heart-wrenching" job that takes a toll on everyone involved.

Jacobs supervises the program's special-care unit, which can house up to 10 patients at a time, most of whom are suffering from dementia or Alzheimer's disease, an affliction that is marked by progressive mental deterioration.

Two years ago, he came up with the idea for an outreach program, involving visits to the homes of patients suffering bouts of mental confusion. Leslie Wither, a spokeswoman for Valley Hospital Medical Center, said the concept, which evolved into the Eldereach program, appears to be the only one of its kind in the country.

The fee for a house call is $25, though that is sometimes waived. It hardly pays for the time involved.

Typically, the first visit is made by a nurse who works with Jacobs, Marlene Harrison. In many cases, Harrison is able to take care of the problem, either by helping the patient with medication or finding someone to do shopping and take care of other needs.

If the patient appears severely impaired and refuses to visit the doctor, Jacobs is called out, which usually happens about once a month. Out of 100 patients who have gone through the program since its inception, approximately 20 have required admission to a nursing facility of some type.

The visits can be psychologically grueling for everyone involved, not the least for the doctor, because the people he sees are in a mental twilight. They may be confused enough that they wander the streets and forget to pay their bills, but they are not so confused as to no longer care whether they remain independent. They are able to appreciate the danger confronting them when Jacobs arrives at their doors.

On a recent morning in North Hollywood, Jacobs rolled up on his Yamaha 700, climbed off and joined Harrison in front of a crumbling, two-story apartment building. They had come to see Mildred, which is not her real name, a 76-year-old woman from Missouri who had worked many years in the garment industry and had once even sent a dress to a fancy European wedding.

Lately, however, she had begun to have delusions. She kicked her grandson out of her apartment because she thought he had attacked her. Then she stopped paying her rent and cashing her Social Security checks.

As a consequence, the gas and electricity had been turned off and the county marshal was due to evict her in two days.

Still, she insisted to everyone around her, she was all right. When her daughter-in-law took her to visit a convalescent home in Newhall, she recoiled. "I'm not going to live with a bunch of old people," she had said.

Finally, desperate and worried that Mildred would be murdered--she had a habit of marching up to drug dealers in a North Hollywood park and flashing the badge that the local authorities had given her years before as a police volunteer--the daughter-in-law called a local hospital, which referred her to Jacobs.

After conferring for a few moments, Jacobs and Harrison went upstairs and knocked on Mildred's door. There was no answer. Trying the knob and finding the door open, they walked into the dimly lit

apartment, choked with old clothes and frayed furniture. But there was no Mildred. Finally, while Jacobs performed a cursory inspection of the apartment, Harrison spotted Mildred out in the alley. She had apparently fled there when she saw Jacobs and Harrison on the street.

By the gaunt, pinched appearance of her 76-year-old body, she hadn't eaten regularly in some time. A flowered red dress hung on her emaciated frame like drapery.

Though she may not have appreciated the deteriorating state of her life, it was clear that Mildred realized the threat these strangers represented. She knew she was in for a battle and was determined not to go down without a fight.

"He's a lot worse off than I am," she said, pointing a bony finger at a male friend in thick glasses, a worn cap and shorts that revealed unsteady legs the color of whitefish. She was willing to have him go in her place and he made no objection.

"Why don't you come up and talk to us," Harrison said. Looking like she wanted to run, Mildred adjusted her red knit cap and made her way up the stairs.

"I got very nasty and very angry," she explained, apparently in the belief that evicting her grandson had brought this retribution down on her head. "I got real mad at him and told him to leave. I was taking my resentment out on him."

Jacobs nodded, then asked if she knew her son's name. She looked insulted. She stated it, testily.

Jacobs asked where she would go if she were evicted. "I don't know, I'll find someplace," she said. Now there was a gay, nervous quality to her voice.

Jacobs asked what year it was. She looked angry again. "I don't pay any attention to what date it is. If you feel better, it's 1943," she said.

She was told there was no food in the house. "I don't let problems bother me," she snapped.

"You have no idea how disgusting this is," she added resentfully. "After all these years."

Nodding sympathetically, Harrison mentioned that she had given the wrong date. "I have too much to think about," she explained. "I don't live an ordinary life at all."

Finally, Jacobs and Harrison seemed to have made up their minds. "We came here to help you find a place to live," Harrison said. "You need a checkup."

"I refuse to go to a rest home," she said. "A bunch of old ladies sitting around, miserable. I'm not going."

Harrison said it would be better for her to be out of this place.

Mildred snapped again. "You don't have any idea how I think or how I feel. I've been going 90 miles an hour. Sitting in a rocking chair, I would lose my mind in two minutes."

She led her visitors downstairs and into an adjoining building, which she said housed her clothing business. Jacobs poked into dusty corners of a room filled with more stacks of musty old clothes. It was apparent the space had not been used in years.

An ambulance pulled up and two young men in white shirts got out. "You have to go with us," one of them said.

"No, no," said Mildred, panicky now.

They picked her up.

"You let go of me. Help! Help! Help!" she screamed. Nearby, Jacobs and Harrison stood quietly, looking pained.

The two men strapped Mildred onto a gurney. "That's right," she said, "go ahead and tie me up. We're going all the way. Steve!" she shouted to her grandson, who had come up, "go upstairs and turn everything off." Everything was already off, but he nodded.

The ambulance doors were closed and the orange-and-white van started off toward the hospital.

She was to be placed under what is known as a 72-hour hold, which could be extended for two weeks, during which an evaluation would be performed to determine whether she could live on her own with help.

If not, a court hearing would be held to determine whether she should have a conservator, who would be given authority to make decisions for her. Jacobs said the family is involved throughout the process. If at any time they become anxious about it, they have the right to stop the procedure and take their relative home.

Jacobs, a Rutgers University graduate who became interested in Alzheimer's disease while doing research work at UCLA in the early 1980s, readily admitted that the work is emotionally jarring.

"The most difficult aspects are when they have enough awareness to know that you're imposing your will on them. Maybe they were afraid of being placed in a nursing home their entire life. To them, it's almost like you're killing them."

One of the hardest things for Jacobs is to realize these patients will not get better. "It's the toughest field in psychiatry, next to AIDS," he said. "Because with everything else there is some hope. These people are on the way out."

He had little doubt that he had done the right thing in Mildred's case. There was no place else for her. He had hoped that a relative in Seattle might give her a place to live, but that fell through.

She had never been close to her son in Santa Clarita, so she could not go there. In fact, the son said later, the woman he always addressed as "mother," never "mom," had abandoned him when he was young, to be raised by his grandparents. The son and his wife had been struggling for years to keep their own family together. Bringing Mildred, who had always been a busybody, telling half-truths about one family member or another, into a mobile home with several teen-agers was out of the question, said the son. Her arrival would have been like setting off an emotional bombshell. Angry flak would be flying everywhere.

Still, Jacobs understood Mildred's desire to remain free and could not help feeling for her.

"I don't see myself doing this the rest of my life," he sighed.

Jacobs regularly gets referrals from walk-in senior centers as well as from families that are exhausted by the demands of looking after a confused relative. Valley Storefront in North Hollywood, a non-sectarian division of Jewish Family Service, has made many referrals to Jacobs. In fact, when a desperate family calls to ask how to cope with an out-of-control elderly relative, Eldereach is the first place Valley Storefront recommends.

"They give excellent medical care," said Dorie Gradwohl, the director of Valley Storefront.

Gradwohl understands the civil rights concerns in cases such as Mildred's. But she said that when people can no longer care for themselves properly, "we have to supersede personal rights for a person's safety."

Jacobs also does research in dementia and Alzheimer's, and his tireless work was recognized in April at a luncheon attended by government representatives and community leaders, where he was given the fourth annual Professional Community Service Award by the Bernardi Multi-Purpose Senior Center in Van Nuys.

Several weeks after she was first removed from her apartment, Mildred had been placed in a locked nursing home in the San Fernando Valley. Locked facilities contain some of the most difficult patients, and Mildred was sent there because of her tendency to wander.

The tidy facility contained 130 beds and featured a large, park-like area behind the buildings, with wooden benches and ivy growing along the wall. The patients were divided into several types, depending upon the level of care they required. Among this group, some members of which required feeding and were virtually mute, Mildred was only moderately impaired.

But if she saw her future in those blank faces, she did not show it. She had adjusted swiftly to her new surroundings. "I love it," she said, tugging on her trademark red knit cap with the pencil stuck in it, which recaptured the look of the shop girl she had once been. "It's nice here."

She did not recognize a reporter who had come to visit, but was willing to share her thoughts anyway. "I love people," she said.

She no longer recalled being forcibly taken from her apartment. She had come here, she said, because her house was destroyed. Some people had come to help her escape. "They said, 'We're going to give you a little different place to stay. Don't worry, there's an ambulance.' "

Then she added something that suggested that on some level she was well aware of what had happened to her. After recalling some of the events of her past life, including her childhood in Missouri, she paused and said: "There's a lot of things to look back on and enjoy. You don't have to look around and say things are not pleasant."

Over a lunch of pizza that afternoon, Jacobs reflected upon Mildred's case, and upon the ambivalence people feel toward nursing homes. "There's a time and place" for such facilities, he said. Mildred "wasn't coping anymore. Now she's in a facility that provides for those needs. A part of her realizes she's better off now."

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