Geriatrics

That question can only be answered after she has had a swallow study. These tests are done by speech therapists to determine what consistency of foods are safe and what swallowing strategies are helpful in people who have trouble swallowing. In most cases actually thicker liquids are easier to swallow and often the recommendation is to thicken the liquids, but the only safe way to decide what is best for her is to have the swallow study done. You should ask her doctor to schedule on of these tests. 

Certainly types of chairs can cause irritation by the way they rub on your clothes, but would not cause a UTI. If the type of furniture makes you much more warm in your genital area than usual, you could get a yeast infection that might simulate a UTI. Although you can always switch chairs, you might ask your doctor to consider checking for a yeast infection if you think this is a possibility. Finally, feeling the need to urinate without much urine can be a sign of a UTI, which might be completely unrelated to the new chair, so you might need to check that possibility also. 

There are two issues here. One, older people can have a hard time using a standard shower or bath and you might need to put in a seat or handrails to help her. If this is not the issue, however, and she just refuses to ever bathe, and her sponge baths are not adequate, this is considered self-neglect (the blame is on her, not you) and is actually considered a reportable form of elder abuse. You should take her to a doctor and see if the doctor can talk her into bathing. If that does not work, talk to the doctor about getting social services involved. There can even be a referral to an agency called Adult Protective Services that will investigate why she does not bathe and offer suggestions. 

In general, second opinions are worthwhile, if for some reason you do not feel confident in the first opinion (maybe the wrong type of physician, maybe not adequate training for the problem), or if the problem is severe, life-threatening or will be lifelong so that you really need the best answers. Many, if not most, insurances will pay for second opinions, but not third ones. With that in mind, I do usually tell people considering a second opinion, or coming to me for one, that there is no more than a 5 percent chance that the second opinion will give a different answer.

In this case, if the prospect of lifelong incontinence is worrisome enough that you are willing to undergo the time and effort for a second opinion, it would be worthwhile to you, realizing that there is a low chance of getting a different answer.
 

The only ideas I have for this problem are as follows: First, Advair is an inhaler that is know to have a bad taste and sometimes cause people to lose taste for other foods. If this is one of his inhalers, maybe there is an alternative. Otherwise, all of the inhalers need to be rinsed out of the mouth after the inhalation or they can affect the taste. If that is not being done, he could rinse after every inhaler use. I hope one of these will give you the answer.
 

Frequent falls are a difficult issue. Even in a nursing home, there is not staff there every minute all day long, which is usually what is needed to prevent falls. She needs to be on a falls prevention program. If they do not have an aggressive falls prevention program where she is, another facility might be best. She might need things like a belt restraint, a geri-chair, or similar strategies to prevent falls, but again she needs to be in a strong “falls prevention” program.
 

Most Paget’s disease is essentially a skin-based form of breast cancer. Most people with Paget’s will also have a breast cancer in that breast, and treatment is primarily directed at the breast cancer. In the 15 percent of people who have Paget’s with no apparent underlying breast cancer, the usual treatment is removal of the skin containing the Paget’s, and radiation to that area to prevent metastases. That surgery is fairly mild and should have minimal complications. You have described this as ExtraMammary Paget’s. If that means it is not on the breast but rather elsewhere, that is exceedingly rare and I don’t think I could add anything to what the oncologist is saying. 

One thing to discuss is the difference between a UTI, a urinary tract infection, and colonization of the urine, where there is always bacteria in the urine but it is not causing an infection. It is frequent in patients in a nursing home to have the colonization, and if that is the case it is more harmful to treat with antibiotics than to leave it alone. It is sometimes hard to tell if it is an infection or colonization. The urinalysis—looking at the urine under a microscope—can help because in an infection there are a lot of white blood cells because of inflammation from the infection, and in colonization there are not. The other way to tell is by symptoms. An acute change in mental function (including a glassy eyed look) can be one symptom of infection, but only if it is an acute change (if she has been like that for awhile, it would not likely be a symptom). Finally, if the doctor has taken a urine culture and has given her the right antibiotics based on the culture, and she has still not resolved the bacteria in her urine, it is likely a colonization. 

We turned to Laura Feeney AuD, doctor of audiology at The Ohio State University Hearing Professionals in Columbus, OH for her expertise:

The first step would be to visit your father’s audiologist to be sure that the hearing aids do not need any adjustment. If the hearing aids are set appropriately, then secondary assistive technology may be useful. One such assistive device is an FM system. The benefit of FM systems is that they improve the signal to noise ratio, elevating speech over background noise, and cut down on the distance between the speaker and the listener—the speech is directly sent to the hearing aids. FM systems consist of a receiver and a transmitter. The receiver would be attached to your father’s hearing aids, and the transmitter is a microphone that would pick up the speaker’s voice. The transmitter could be worn by one speaker, passed around to multiple speakers, or placed in the middle of a table. If the hearing aids are not FM compatible, there are FM systems that can be worn without hearing aids. Speak to your father’s Audiologist about the most appropriate options for him.

To learn more, go to hearing.osu.edu

This is a problem we see often in elderly patients. The first thing you should do is acknowledge to her that activities are more difficult with aging and ask if you can arrange for someone to help her with some of her activities, such as bathing. If she declines, the next step depends on your relationship with your mother. If it is very good, just be frank with her and tell her that her hygiene is poor and needs improvement. If your relationship is not good enough that you would expect her to accept news like this, you could ask her primary care physician to suggest the need for bathing more often. 

Most loss of vision after a stroke is due to damage of the nerve pathways between the eye and the brain. Recovery of the vision depends on how severe the damage is. Up to 2/3 of people with a stroke will recover some or all of the vision loss eventually, particularly in cases of less severe damage, but it can take from 1-6 months. There is no good evidence that any vision therapy helps this process. There are some eye and neurologic centers that offer Vision Restoration Therapies after a stroke, however, the results are usually mild at best. You could ask the neurologist involved if this is a reasonable option to pursue if the stroke was a while ago. If the stroke was very recent, time is the best therapy.
 

This is unfortunately a very difficult situation. There are many opinions about how to prevent falls from beds in hospitals and nursing homes, but not great conclusive evidence. The best way to prevent serious falls seems to be to have the bed very low to the ground and have a safety mat on the ground so if the person does fall out of bed there is little danger of serious injury. The issue with bedrails is that with bedrails up there are fewer falls out of bed, but the falls that do happen are more serious because they result from people climbing over the bedrail and falling from a greater height. Most specialists in falls suggest not using bedrails for that reason. Another safety feature sometimes used is a bed alarm that sounds when someone is climbing out of bed, but those have been shown to not help reduce falls because by the time a staff member responds to the alarm the person has usually gotten out of the bed (and fallen if it is a fall situation). People on Klonopin are at greater danger of falling.

The best solution would be to ask if there can be a low bed with a mat next to it. I do not know of any regulation preventing bedrail use, just the worries that are mentioned above. Places that use bedrails usually make sure to inform the family of the dangers associated with them, which includes not only the more severe falls when they do happen, but also people
getting tangled in the rail and injuring arms or legs by the tangling.
 

There are two important considerations in your question. First, in addition to diabetics, women and older people may have silent heart attacks. Heart attacks are much more common in people with risk factors for heart disease, which include hypertension, high cholesterol, diabetes, smoking, obesity, lack of exercise and family history of heart problems, but people with little to none of these risk factors can have heart attacks also.

The second, and possibly more important consideration, is that the EKG may have been interpreted incorrectly. Most EKGs these days have an automated interpretation by a computer, and those are often incorrect. I have seen this computer interpretation often diagnose a prior heart attack, that on more expert review of the EKG is not suggested. I would ask the doctor if a cardiologist overread (meaning also reviewed the EKG) it and if the cardiologist also thinks an old heart attack or two old ones are suggested. It might also be helpful for a doctor to look at an old EKG of yours, if one is available, to see if there are changes from before. A lack of new findings on the EKG, particularly if any available prior EKG was from a while ago, also makes a heart attack less likely.
 

There are two issues to discuss for your problem. In terms of the wandering, it is believed that people who have abnormal mental function often wander because they are looking for something, but due to their trouble thinking they are not sure what it is. Medications do not help this, and in fact in facilities that specialize in dementia the wandering is often encouraged because stopping or preventing it can be frustrating to people with dementia.

The bigger issue for her may be to figure out why she has had the decline in her mental state. She may have developed dementia, which is a term for mental deterioration that has several causes, the most common of which is Alzheimer’s disease. However, there are often correctable causes for mental status deterioration such as side effects from medications, other new medical conditions, abnormalities in blood tests such as low sodium and psychiatric issues such as depression. She should be evaluated for the cause of the decline in mental function. If it is correctable, the wandering may stop.
 

One thing that can cause this is termed fecal impaction, which means that there is severe constipation and the only stool that can get out must be loose stool that leaks around the area of the constipation, often several times a day. The only way to find out if this is the cause is for someone to do a rectal exam and feel for a mass of hard stool. If this is not found, then his medicines, particularly the Omeprazole and maybe the Sulcrafate, could be the cause.

He needs an extensive neurologic examination. With normal scans the likely causes focus on nerve damage, with multilple possibilities such as Guillian-Barre syndrome, which do not show up on lab testing or scans. Sometimes a neurologist will do an EMG test that can also help diagnose the cause.
 

Unfortunately I do not have any additional suggestions for the neuropathy. You are on the maximal dose of those medications and those are the recommended treatments for diabetic neuropathy. Getting your diabetes under control also can help but your A1C is at recommended levels. 

There are several issues here to address for you. First, yes the Ativan can be causing all of your Dad’s symptoms. Your father is on a very high dose even for a young person, and particularly for someone of his age. There are other possibilities of what could be causing his symptoms, however, and he should see someone with knowledge in this area as suggested below. Unfortunately, also, Ativan is very addicting and has severe withdrawal effects. He really should get off it, but that requires a very slow withdrawal over several weeks at least. The preferable drugs for depression with anxiety component for an older person are celexa (citalopram) or Zoloft (sertraline). As for what doctor could help him, the options are a geriatrics specialist preferably or if not available a neurologist, general internist, or even a psychiatrist. 

It would be difficult to say that there is a number one cause. The most common causes would be related to medications, dehydration, poor heart function or due to aging of the nervous system. The most common medications to cause this are blood pressure or heart medications, with pain, anxiety, depression and prostrate medications also capable of this. Dehydration causing low blood pressure is most commonly from diarrhea, vomiting, or being too sick to take in fluids. Systolic heart failure, if severe, can cause the heart muscle to pump poorly and lower blood pressure. Finally, up to 20 percent of elderly people will have orthostatic hypotension (low blood pressure only when sitting or standing) due to a change in autonomic nervous system function with aging. While sepsis frequently causes low blood pressure, it is fortunately uncommon. Merely having a diet low in salt can cause low blood pressure, but this is also rare.