Annals of Long Term Care

To the Editor:
I wish to share my growing concern about medical care for the medically complex geriatric patient. My dad recently turned 90 years old (on 3/3/08). For most of his life he was healthy and active, looking, feeling, and acting much younger than his age. Twelve and a half years ago he was diagnosed with prostate cancer; that was kept under control with appropriate medical intervention, and Dad was able to go on with his life without much change from the condition. He continued driving and was a good driver up to age 86.

On August 11, 2004, my father sustained a traumatic brain injury due to a fall on a broken sidewalk. (This was not a senior merely losing his balance—the sidewalk deficit was invisible from just above it.) Immediately afterwards, Dad was alert and able to speak, and share with the ambulance attendants all that had occurred. He remained in the hospital for 1 week, during which CT scans showed that the blood clot on the brain had initially decreased in size, then remained stable.

The social worker at the hospital (NY) informed us that Dad would require a period of rehabilitation before returning home. He determined that, due to Dad’s age, he would require subacute, rather than acute, rehab and should be admitted to a skilled nursing facility (SNF) for short-term rehab. He gave us a list of SNFs in the area in which my parents reside. We selected a facility not too far from their home, one that was reported to have a “wonderful” rehab department.

The trouble began almost immediately, but gradually. First, the doctor in charge recommended that we wait until Dad’s release (which we thought would be 3 months) to reinstate his prostate cancer treatment. Then, they continued to administer phenytoin in greater and greater dosages, as Dad’s body was not absorbing it; this was despite the fact that he had never been determined to have sustained a seizure. For 3 1/2 weeks, Dad did well in rehab, then began to deteriorate, becoming more and more lethargic. When my mother and I expressed our concern to the supervising nurse she stated, “He’s just tired, but he fights when we try to dress him.”

We continued to express our fears, and finally another supervisor called the doctor. They sent my father to the ER for a CT scan, which revealed that the blood clot had enlarged and liquefied. He required emergency brain surgery to have the clot drained. HAD MY MOTHER AND I NOT BEEN THERE INSISTING SOMETHING BE DONE, DAD WOULD HAVE DIED THAT NIGHT.

After five days at the hospital, Dad returned to the SNF and went back to rehab, although now he was nonambulatory and unable to do all that he could before. Then he began to become severely lethargic again. He was sent for more brain scans, which revealed no changes.

He went back to the neurosurgeon for a follow-up (3 months post-surgery), and it was thought that the phenytoin might be causing the lethargy. As he had no seizures, the neurosurgeon recommended weaning him off the phenytoin. At the facility, the consulting neurologist stopped it entirely all at once. Thankfully, no seizures.

Shortly after the neurosurgical follow-up, we expressed concern to the nursing home staff at the facility that we couldn't awaken Dad. The day supervisor said that the doctor would see him “when she comes in tomorrow.” They didn’t view it as an emergency. The next afternoon, I received a call at work that they were rushing Dad to the ER “because we cannot wake him up.” It turned out that he had sepsis and a severe urinary tract infection. He ended up with a gastrostomy tube, and they thought he wouldn't survive, but he did and became responsive and interactive again.

We finally realized that the recurrent UTIs were due to the enlarged prostate. They still refused to treat the cancer until I obtained some information from a doctor online, and in June 2006 he was back on medications.