When No One Else Sees the Patient’s Problem

When I first started seeing Mrs. B three years ago, I knew she was sometimes forgetful. I figured at 80 years old, who wouldn’t be?  But it became apparent to me over the years, that she was forgetting more and more. For someone with insulin-requiring diabetes, this is not a good thing.  At her office visits, she would ask me the same questions over and over.  Questions to which someone who has had diabetes and has been on insulin for decades should know the answer.  "Bread is a carb?" "I eat cookies or cake at bedtime, that's OK, right?"  "When am I supposed to take my insulin?"  "What do I do if my blood sugar is low?"  These are questions I have answered many times for many patients, but not multiple times in one visit and at every visit.  I have written instructions for her and have had her read them back to me.  One time, she rewrote it twice on the same piece of paper I wrote it on, and then still called the office as soon as she got home because she didn't know what to do.  Speaking of phone calls, she calls the office frequently, sometimes multiple times a day, asking the same questions. Calls started coming because she would take the wrong kind of insulin at the wrong time of day. 

I have been concerned about her safety for some time now.  She lives by herself.  Until recently, she was still driving.  One day, I received a form from her for the Motor Vehicle Commission asking if I believe that she is capable of driving safely.  I couldn't do it.  I could not fill out that form and say that she could drive.  I received a call from her son.  He wasn't happy and neither was she.  I expressed my concerns.  I was afraid she would get hurt and maybe hurt someone else.  He said he had her drive him around that weekend and she was fully capable, she knew where she was and what to do.  OK, in the comfort of her own neighborhood, with her son at her side, she did well.  However, she got lost every time she came to my office, sometimes for an hour or so.  I told him I was concerned about her memory and he said, "She just gets nervous when she's at the doctor's office," and that's why she keeps asking the same questions.  I still refused to fill out that form.  Apparently, they were able to get somebody else to do it for them, because she showed up at the office unaccompanied a couple more times.

At her last two visits, I was relieved when she came in with an aide.  The aide drives her where she needs to go and is with her for a few hours during the day.  This still leaves a big chunk of time when Mrs. B is alone; alone and terribly confused about her meds.  Last week, she called multiple times, unsure of what to do.  I spoke to her aide who was fairly certain that she mixed her meds up again.  She ended up in the hospital with a glucose of 700.

When I went to see her, she did not remember me.  She was awake and alert, and if you never met her before you would figure she is perfectly capable.  But it only takes two minutes to realize that her short-term memory is all but gone.  She insisted that no doctor had seen her all day and that her primary-care physician (whom she has been seeing for years) didn't know she was there, even though he had been there only hours before. 

What got me was that he wrote in his note that she was not confused.  Only anxious.  Really? Am I the only one who sees this? She has no recollection of calling my office,  no memory of ever mixing up her insulins,  and even though I see her every day in the hospital and reintroduce myself, each day, I am like a stranger to her.  She blows it off by saying, "Oh, I just didn't recognize you because I don't see you very often."  When I say, "I saw you yesterday," she replies, "Well, if you say so."

I talked to the admitting physician and shared my concerns about her going home alone. I said that she needs full-time 24 hour help. He responded, "I know, but she won't change.  There's only so much you can do."

I don't know what else to do.  Her family thinks she is fine.  Her primary-care physician thinks so, too.  A friend of mine said, "Well, what do you want them to do? Put her in a nursing home?"  Maybe, or get her a 24-hour aide or move in with her family.  I don't know.  All I know is I fail to understand why no one else sees a problem with her being all alone.  Maybe it's me.  I only hope that if I ever become like Mrs. B that somebody notices and tries to keep me safe.