Last November, my wife and I invited an elderly relative, Uncle Josh, to spend the winter with us. He was 82 years old at the time and turned 83 during his stay. As soon as he accepted our invitation, we began preparing.
The winter went well – most of it – with our guest staying from mid-November to mid-April. There were a few occasions when living together was a bit tense, but everything worked out and we were sad to see him leave. Let's look closer at Josh's story, which provides insight into some of the age-related issues your senior patients may be experiencing and how you can best serve them as a doctor of chiropractic.
Tough Decisions With Age
During Uncle Josh's visit, I was reminded almost daily of how we decline with age and how difficult it is for us all to admit our senses and skills aren't what they used to be. He had lived independently for almost 17 years after his wife passed away. His home stood on several acres of land, and he loved flower gardening, growing vegetables and general yardwork. He loved being outside, still drove himself everywhere and was quite active in his community.
Unfortunately, two automobile accidents forced Uncle Josh to give up driving. Soon after, two minor strokes resulted in his hobbies and the maintenance of his property becoming difficult and burdensome. His car was gone, he could not garden like he used to, and the difficult decision to sell his house and property was made. That is when Josh came to live with us.
During my career, I've recommended to several patients that they should give up driving, move to assisted living and/or move in with relatives. These were always difficult tasks. Despite the difficulties I had in recommending these decisions, it was much more difficult for the patients receiving the recommendations.
Not surprisingly, Uncle Josh was depressed when he moved in with us. Nothing seemed right; after all, it was not his house. Josh came to us from another state and the only people he knew were my wife and me. He missed his home, his friends and his church.
When the Body Betrays
Josh's doctors felt he had two residual effects from the strokes he'd suffered: his right eye would not shut completely and his speech was slightly slurred. However, Josh neglected to tell anyone at the hospital (and later the rehabilitation facility) he had suffered a significant case of Bell's palsy 10 years earlier. His right eye had not shut completely since that time.1 Josh also wore dentures that did not fit properly. This slurred his speech slightly. He could actually speak better without the dentures in place.
I pointed these things out to the doctors during his short stint in rehab – "short" because Josh checked himself out and went home as soon as he could get someone to agree to take him.
After the initial stroke symptoms resolved, Josh did not have any dysfunctions that had not been present prior to the stroke. His hearing, eyesight, sense of smell, sense of taste, balance and memory had all been declining. These declines in function are all typical of the aging process.
Josh could not hear well. Statements and questions to him had to be repeated frequently. He frequently gave strange answers to questions since he was responding to what he thought had been asked, not what actually was asked. When he watched television, he kept the volume up so loud that you could not hear anything else in the house.
Ordering in a restaurant and interactions with customer-service people were difficult. He would not ask strangers to repeat their questions or answers. He would just nod his head during these conversations. This often resulted in not receiving the service he expected and he would immediately become angry.
When we suggested he see an audiologist to be assessed for hearing aids, he insisted he did not need them. His reply: "Everybody talks too soft. Your generation mumbles everything. Why can't you speak up?"
Without the benefit of auditory testing while Josh was here, I assumed he had presbycusis, or hearing loss due to aging. Thirty-three percent of people over the age of 65 have hearing loss and more than 50 percent have hearing loss after age 75. The most common cause is simply gradual loss of function of the structures and nerves associated with hearing.2 This loss can be accelerated in onset and severity by noise exposure, diabetes, high blood pressure and drugs toxic to sensory cells of the ears.
Josh refused evaluation while visiting us. After he left, he did pursue an evaluation and obtained a hearing aid. He needed two hearing aids, but would only accept one. Presbycusis was the diagnosis rendered for ordering the hearing aid.
The loss of hearing with age is a concern for seniors, as it makes it difficult for them to hear the television, alarms, doctors' advice, the telephone, etc. It creates other indirect dysfunctions in their lives. In Josh's case, we were not sure if his difficulty with doctors' advice was his hearing or his stubbornness.
While Josh wore glasses, it was obvious he could not see. This prevented accurate use of the microwave oven, the gas range and other household appliances. Josh wanted to help cook, but he programed the microwave for 20 minutes to warm up something that usually requires 2 minutes. He could not tell if he had turned the gas range off completely, which resulted in two instances in which the gas was left on for prolonged periods. This was complicated by Josh's age-related loss of his sense of smell.
Josh submitted to an eye examination near the end of his time with us. His trouble was diagnosed as macular degeneration, the most common cause of vision loss in people over age 65. It is accompanied at the top of the list by cataracts, glaucoma and diabetic retinopathy.3
Joe had laser surgery just before his departure. His vision improved and the day after the procedure, he was going through the house looking at everything. He read labels, the TV remote, everything. He seemed completely amazed at what he could see. This helped him eventually realize his hearing was as bad as his eyesight.
As mentioned, Josh also had deteriorating sense of smell, or presbyosmia. Only 2 percent of people under age 65 will have problems smelling. Thirty percent of people over age 70 have a decreased sense of smell; 33 percent over age 80.4 This was accompanied by a declining sense of taste (ageusia).
Smell and taste are separate neurological functions, but they are closely linked in the brain. In some cases, patients will think they are losing their sense of taste, but they actually are losing their sense of smell. Loss of smell is more common than loss of taste.
Josh like to cook and would frequently make his favorite dishes for us. Since he had lost most of his ability to taste salt, by the time he seasoned what he was cooking to his taste, we could not eat it. Everything tasted like pure salt. We finally convinced him I was trying to watch my salt intake and asked if he could salt his food to taste once it was served. Salt was not in Josh's best interest, either, but it was difficult to discuss his salt intake. Just like the hearing problem, which he attributed to mumbling on our part, Josh told us, "You don't know good food when you taste it. You just don't know what's good."
Putting Josh's Story Into Chiropractic Perspective
So, why is Josh's story important to us? Baby boomers are aging and many are now Medicare recipients. As such, they represent a growing percentage of elderly patients in our practices, a trend that will continue for several years. The age-related dysfunctions discussed here affect them, and you will be required to identify and/or deal with them during your examination process.
When I was teaching interns, it was not uncommon for one to consult with me about a patient he suspected of having multiple cranial nerve lesions. Typically, the patient turned out to be an elderly individual with multiple aged-related sensory dysfunctions. This was inexperience, but later, experience can lull us into a false sense of security, such that we always assume the losses are age related. We must not let the fact that these dysfunctions are common with age prevent proper examination and differential diagnosis to rule out possible pathological causes. This means performing cranial nerve examinations.
Ah, yes, the 12 cranial nerves (CN). Do you remember them? Do you remember their names? Let's name them: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12. Ha! So many chiropractors stop examining the cranial nerves routinely. This is partly because many of the abnormal findings are simply age-related decreases in function. Knowing the difference in symptoms and residuals of a stroke and Bell's palsy (CN 7), pathological losses of sight (CN 2), hearing (CN 8), taste (CN 7, 9 and 10) smell (CN 1), and typical age-related deficiencies is now more important than ever.5
Josh also had balance and mental acuity difficulties. They were the least noticeable of his difficulties, but are two significant risks for seniors. Balance issues result in large numbers of falls in the elderly population each year. Memory loss can result in other dangers.
Prior to her death, Josh's wife started a house fire while cooking. She placed items on the stove, walked off and forgot to return. This is a reminder that for many seniors, forgetting to take medications and follow other health instructions also can have bad consequences and must be considered during the clinical encounter.
As I said, the winter went well (except for the sparking microwave, near gas explosions and salt poisoning). Although we tried to convince him to stay, Josh returned to his former hometown. He purchased a little house with a tiny yard and no steps to maneuver inside or out. He cooks on an electric stove, and has a medical alert system and other safety devices. He is doing well and happy to be independent again.
References
- Murthy JMK, Saxena A. Bell's palsy: treatment guidelines. Ann Indian Acad Neuro, July, 2011;14(5):70-72.
- Age-Related Hearing Loss. National Institute on Deafness and Other Communication Disorders, U.S. Department of Health and Human Services, 2014.
- Quillen DA. Common causes of vision loss in elderly patients., Amer Family Phys, July 1, 1999;60(1):99-108.
- Problems With Sense of Smell in the Elderly. National Institute on Aging, 2015.
- Miller KJ. "The Practical Neurological Examination, Part 2: Assessment of Cranial Nerves." Dynamic Chiropractic, April 9, 2011.
Click here for more information about K. Jeffrey Miller, DC, MBA.