Don’t Let ‘em Fool You

Tuesday, July 8th, 2008

Elderly patients always seemed very tricky regarding their reporting and response to treatment. Either I could not get a clear case or there were so many aggravating factors that characterizing the illness was difficult. Give them a remedy and when assessing the follow up carefully there is either no clear response or it seems I have made them much worse or created a side effect. During the first years of practice I used to dread two kinds of patient. The very old and the very young.

In dealing with the elderly precision case taking is very important (that seems like a silly statement-isn’t it always?).Be insistent on a clear etiology. “When did the problem first come to be noticed?” Establish a time based frame. A particular day, week or season-something definite.” What had happened in life just before?” Repeat the patient’s description of the event and wait a moment while watching their face and body, observing for a change toward discomfort or emotion. “OK that’s what happened on the outside, what was the inside response?” If the patient lists several emotions write them all while underlining the one that is accompanied by a body language emphasis. “That was an important one? (Wait for acknowledgement) say more about that feeling.” The elderly are often reserved or dismissive of their emotions and much patience and observation is required. Sometimes tense facial cues indicating a holding back of expression are important so just watch the face for changes (expression skin color, moisture, pupil size,) and question the patient regarding their feelings when it happens. “That last comment seemed to have an impact-what was that?”

Precise locations are verified by pointing using one finger. Later again verified by physical exam. Ask to be shown which movement exactly hurts by demonstration. Create a hierarchy of modalities through indication from 1 to 10 how intensely each factor aggravates. An astute care-taker is very valuable observer for both the elderly and infant (and pet).

Lastly the rubric in the repertory Generals.Old.people, complaints in is useful.

Brian was in his mid 80’s.His wife of 4 decades had passed after a prolonged bout of cancer. Brian was totally devoted and this trauma had been devastating. The response to Ignatia and the Natrum Mur was very good. There was a nagging decline in vigor that really was not characteristic of any remedy.(one of the most important “thinking tools” I teach in my post graduate course is “know when you don’t know” ie if you see no characterizing elements in a complaint don’t scratch too hard for them-there is a danger that the temptation to deduce will be too strong. If there is nothing peculiar accept this and look elsewhere in the case or wait.) Soon a new complaint did develop. The patient became forgetful and on question noted that the lapses of memory were accompanied by an upsetting sensation in the head “as if air were in the head”. Further inquiry revealed it was not a sensation of wind, draft or other movement of air. It had no temperature associated. Just can’t explain it other than to say its as though there was air in the head. Now the rubric in the repertory is “as if air passing on and through the head”. This is not so satisfying. A computer search of the precise symptom leads directly to the reading of Benzoic acid. “Sensation as if there were air in the head”, “Tired feeling in the head as if from night watching”(staying up while caring for the sick) and the mind symptoms “confused head. Omits words while writing”(Hering).Now Benzoic Acid was in that original rubric but only a literature search and a reading of the actual symptoms could lend any feel of assurance that the remedy fit well. This is usually the case. Notice that there was no direct mention of memory loss but that the two named symptoms certainly frame the situation well. Benzoic Acid 30 was given. One dose per day. In just a few days The state and the symptoms lifted nicely.

I recall a case of a senior, a charming lady whose daughters and grandchildren I had treated. Amazingly both daughters responded well to Phosphorus. She had very similar general symptoms and I thought this one was a slam-dunk but no. Her complaint was a rapidly advancing vision loss and increasing dementia with anger. There is a rubric “loss of vision with delirium” which could approximate our situation but the remedy is phosphorus which did not work. In this case a careful re-visitation to the onset revealed our patient did not feel well after a flu shot and it seems the trouble started up with in a couple of weeks. One dose of influenzinum 10m yielded a truly remarkable improvement in the mood and memory with a slow improvement in vision. Here the etiology was the needed clue to a nosode based on “never well since”.