February 24, 2006, is my parents’ sixtieth wedding anniversary. My family plans a brunch for them in their home. We are keenly aware that this may be the last anniversary my parents will celebrate together. It won’t be an elaborate party, just a bittersweet one. Seven years earlier, my father was diagnosed with Alzheimer’s disease, and he has gone steadily downhill. At 87 years old, he is now a prisoner of his mind. His agitation and paranoia arise from distorted memories, nightmares he can no longer separate from reality. A few days before the brunch, my mother calls me in a panic. My dad is bellicose and paranoid, accusing. Summoning Yiddish profanities he has not uttered in 75 years, he curses at Yolanda, the caregiver who holds everything together in my parents’ household. He will not be bathed or shaved. He will not eat, refuses his medications. He is raving.
“Dad,” I say when I visit their house that afternoon, “what is it? What’s wrong?”
“I want to go home. Please, take me home!”
“But, Dad, you are home.”
“I don’t know where I am. Please, Jerry-boy, take me home. You know the way
“I don’t know where else to take you, Dad. You’ve lived here for twenty-nine years.”
“You go to hell! You’re in with them!”
There is no walking away now. He is an abandoned child. He searches for his boyhood home on Boarman Avenue, in Baltimore, or perhaps our first family home there, on Forest Park Avenue. He hears voices but can’t decode what is being said, and his mind assumes the worst: My mother is insulting him, planning to run off; his sons are belittling him, his mother scolding him, his older brothers and sisters teasing him. He is lost, with no father of his own to turn to. I see that he has wet himself; a dark ring marks his place on the couch.
As a geriatric physician in San Antonio for the past thirty years, I have been through this before. I have been cursed, spit on, bitten, and punched by demented old folks over the decades. A poor woman threw a shoe at me when I stepped inside her hospital room. The day before, she thought I was the devil.
As a doctor, I know what to do; as a son, I am uncertain. So I assume my doctor role, retreating into the armor of my starched white coat. I walk to the kitchen and check his daily pill slots to make sure he’s been getting his regular medications. Sometimes my mother, unable to see due to macular degeneration, inadvertently leaves pills in the plastic containers I fill every couple weeks. But everything seems in order.
The pills are often as much a part of the problem as the cure. My father takes eight medications a day; my mother, who is 82, fourteen. They are both on vitamins and minerals, blood pressure medications, diuretics, and cholesterol-lowering drugs. My father also takes two pills for his heart. My mother takes drugs for her diabetes, a thyroid disorder, osteoporosis, and depression. This is not unusual for folks their age.
I spend my doctoring days prescribing medications for my patients, reshuffling the ones they’re on—a tiny dose change here, a retiming of administration there. By now I have written or refilled hundreds of thousands of prescriptions, but my constant goal is to cut back on medications, stop them altogether if I can: Less is usually more. Every geriatrician knows this. Looking through my father’s pills, I recall a patient of mine, Lilly, a woman who first came to see me carrying a brown paper shopping bag crammed with pill bottles—at least forty different drugs prescribed by a dozen physicians.
“This one’s for the high blood,” she had said, “and this one’s for the sweet blood, and this one’s for the low blood. These three are for my bad knees, and this one’s ’cause I’m sad a lot, and this one’s ’cause I don’t sleep too good, and this one’s ’cause I’m tired all the time. I can hardly keep ’em straight, but I got a big list at home tacked to the wall, over the phone in my kitchen. Last month the company cut off the service when I couldn’t pay the bill. All these medicines and still I feel so bad. That’s why I come to you now. That and all these other troubles.” She had handed me a list of symptoms, pencil-scrawled on a ragged piece of paper.
I spent two hours with Lilly, hearing one story loop into another: bad marriages, kids in jail, ER visits, surgeries, strange diagnoses mostly self-made. I knew what was happening to Lilly, what happens to many people like her in a medical encounter. The physician begins to drown in a sea of conflicting information, feels powerless to alter the circumstances of this person’s life. A wave of helplessness washes over doctor and patient both, and he reaches for his prescription pad. “Here, try this,” he says. “I think it will help.” Then he steps into the hall, picks up the next chart, and moves on, hoping the drug he has prescribed helps but doubtful it will. I could not change the circumstances of Lilly’s life, couldn’t make up for her poverty or lack of education or the poor choices she had made. But she improved significantly when, after some lab work and many more hours of listening, I was eventually able to whittle her medication list down to three.
Prescribing for the elderly is complicated. They don’t metabolize drugs at the same rate as younger, healthier patients. The main workhorses of drug excretion—the liver and kidneys—decline in function with age, as do all our organ systems. The elderly, like my parents, are often on multiple drugs (including over-the-counter preparations the doctor might not even know about), and the incidences of unforeseen interactions begin to mount. We know so little about these interactions. Indeed, the pharmaceutical companies are infamous in geriatric circles