Friday, April 22, 2005
As a review of the last few months...
...during which I have not been entering regular reports of my mother's progress here I thought it might help those of you who follow her progress to publish parts of the letter I faxed to her PCP's office in Mesa upon the occasion of her first spring blood draw (without identifying markers). Some of the information is a repetition of information I've already published here. Some is not. My intention is to reorganize this letter into a standard monthly report that I will fax to her PCP every month at blood draw time so that the data contained in the blood draw will have some meaning in the context of my mother's days. This first one, though, was written off the cuff without any thought to organization or brevity.
First though, I should mention one aspect of her care which I neglected to mention and intend to include in subsequent PCP reports is Skin Condition. This remains excellent, since I solved the problem of redness, itching and (upon being scratched) irritation and broken skin in the creases between her pudenda and thigh area by using a non-oil based anti-itch cream which not only stopped the itching but healed the slight abrasion and keeps her skin protected from the consequences of nightly exposure to her urine. As well, she maintains excellent circulation, including in all her extremeties, thus she does not develop ulcerations. She is slathered with lotion at least once a day, sometimes twice. As I bathe her every morning I perform a minute inspection of her skin which allows me to note any problem areas and address them immediately (although she has yet to develop problem areas other than her thigh creases).
Update for Readers:
She has, within the last week or so, been moving a bit less and sleeping a bit more than mentioned in the above letter. We've been swept by the southern edge of a series of non-precipatory lows. I've observed that lows tend to slow her down.
Her blood sugar levels at lunch have begun to drop. A couple of times before I switched to breakfast readings this last Sunday I actually recorded some normal readings. My guess is that this is a sign that her diabetes is "going on vacation", as The Wondrous FNP predicted that it would. I am maintaining her glipizide dose but after a couple of weeks of exclusively morning readings I'll probably shift to a few weeks of three readings a day to see if I need to drop back on this medication. Of course, the extra movement may also be doing its job, as well. We'll see.
Of her own accord a few days ago when we had a particularly sunny, still, relatively warm day she walked out into our backyard to observe how it looks now that the hands of Mr. Everything are being applied and flora has begun to leaf out. "It's relaxing to look out here. We're lucky to have this place," she said. It is and we are. A day doesn't go by now but what she doesn't stand behind the Arcadia screen door and watch the goings on of the birds and animals in our back yard for a few minutes. I haven't convinced her yet to spend time out there but our weather is still bouncing between short periods of warmth and extended periods of coolness. I expect that when it becomes predictably warm during the day I'll be able to convince her to eat meals out there, wander around (under my watchful eye) and supervise my yard work.
A couple of days ago I talked at length with a nurse whose entire family, but primarily her mother, is involved in the care of her maternal grandparents, the grandmother of which has had to be admitted to a skilled nursing facility close to the family in Prescott Valley. Aside from gathering some very valuable information about which nursing homes in the area are the best and the problems surrounding those that are not very good, she treated me to a detailed history of the elder care in her family.
I remember this nurse telling me the following about her grandparents:
My impression is that I'm actually quite lucky in that, firstly, my mother and I have a life-long excellent relationship; secondly, I am not contending with elderly parents who are divorced and can't get along with each other nor with a history of contentious family relationships; my mother is not laxative dependent nor (normally) bowel incontinent; her senility is not following the classic patterns of Alzheimer's which include inappropriate and fierce displays of sexuality; paranoia regarding those with whom one is surroundeded; hiding of personal possessions; inappropriately divesting oneself of personal possessions (including giving away sets of furniture, stereo systems, jewelry and other items of value, as well as money to strangers, which the above mentioned grandmother did); extreme displays of verbally and physically abusive behavior toward loved ones.
The future, of course, is hazy at best. Who's to say whether my mother's dementia will advance to avocationally unmanageable proportions or that she will suddenly suffer a series of heart attacks, strokes or organ failure that will deliver a stark mark of quick decline upon her trek through Ancienthood? At least, now, I'm not worried about my ability to do the right thing by her. So, we take it minute by minute.
Today it's cool and cloudy. Yet another precipitous low is approaching which should deliver the bulk of its rain starting tonight. Mom's sleeping in after a late evening. Today would be a good day to do her hair. It'll keep her up for awhile, she loves the head massage and hair play it involves and, anticipating a cool day, I've promised to do some baking (probably scones) to warm up the house and keep the glow going within the cockles of her heart (sometimes I wonder, considering my mother's life long love of sugar, if the phrase, when applying to her, should be amended: "The cookies of her heart". We'll probably watch Thelma and Louise. She mentioned last night, during a commercial on one of the movie channels for it, that she'd, "...like to see that one, it looks interesting."
So today we'll be nesting. The Little Girl has alerted me that The Mom is up.
Later.
First though, I should mention one aspect of her care which I neglected to mention and intend to include in subsequent PCP reports is Skin Condition. This remains excellent, since I solved the problem of redness, itching and (upon being scratched) irritation and broken skin in the creases between her pudenda and thigh area by using a non-oil based anti-itch cream which not only stopped the itching but healed the slight abrasion and keeps her skin protected from the consequences of nightly exposure to her urine. As well, she maintains excellent circulation, including in all her extremeties, thus she does not develop ulcerations. She is slathered with lotion at least once a day, sometimes twice. As I bathe her every morning I perform a minute inspection of her skin which allows me to note any problem areas and address them immediately (although she has yet to develop problem areas other than her thigh creases).
April 14, 2005
TO: My mother's PCP (specifically, The Wondrous FNP)
If you have not already, you will soon begin receiving, by fax from Bradshaw labs, the results of [my mother's] monthly blood draw (CBC and BMP) and urinalysis, taken yesterday, April 13, 2005. I thought the results would make more sense if I reviewed for you how things have gone with her since her last appointment. Her last draw was on January 21, just before her last appointment with you on January 24th. I haven’t taken her in before now because she hasn’t wanted to go and, overall, she’s continued in good, unchanging condition since her last blood draw. She’s finally thawing from winter and I didn’t find myself moving into “harrassment mode” in order to get her to the lab, so yesterday was a good day. My expectation is that as she moves and gets out more we’ll be going for her blood draws on a regular monthly basis.
URINARY TRACT INFECTIONS and URINARY LEAKAGE:
Within a few days of her appointment she was bleeding from the urinary tract again. I filled the prescription for Levaquin 250 and administered it once daily for 10 days. Without thinking, I simultaneously started her on the samples of Detrol LA. Again, a few days after she finished the prescription she was bleeding from the urinary tract. This time, after refilling the prescription, I doubled up on the dosage (2 per day), administered it for 7 days and took her off the Detrol (which was having no observable effect on her leakage). That took care of the infection. Thank you very much for writing the prescription so that, if necessary, I could administer it at a dosage of 2 for 7 days. It seems this worked the best. We still have 2 refills left on the prescription and she has been UTI free (at least as far as I can tell) since February 16th.
A little over a week ago I decided to once again try her on the remaining samples of Detrol LA to see if administering it when she is UTI free made a difference. The only difference was that she began retaining fluid, especially in the abdominal area, so I stopped the Detrol four days ago and her body has gone back to processing fluid normally (for her). I think Detrol simply isn’t a good idea for her, now. Her leakage continues, especially at night, as it has for somewhat over a year. We just deal with it.
ENERGY LEVEL:
Low, which is typical for her in winter. She hasn’t had any episodes of unusual confusion or displays of collapsing behavior that would indicate low electrolytes. Her energy level is picking up (slowly), typical for spring. Within the last week we’ve reinitiated very moderate exercise every other day, primarily the therapy exercise routine prescribed by the skilled nursing facility last fall. As usual, it takes her very little time to advance in reps and difficulty. She has expressed interest in “getting out”, again, so within the next day or two we’ll be alternating her exercise days with walkering days.
She continues to sleep about 12 hrs/day, both in naps and night sleep. Over the last month she’s been arising anywhere from an hour to two hours earlier than was normal during the winter. This is also typical for her when spring sets in.
OVERALL:
Spirit and will remain strong and feisty.
Dementia remains stabilized.
Diabetes remains under good to excellent control.
I’m practicing your suggestion to lay off the constant testing of her blood sugar and blood pressure. I test only once a day, if that, and alternate periods of testing before breakfast, before lunch and before dinner. Blood sugar consistently runs at normal in the morning, from normal to the high 100’s before lunch, and normal to between 110 and 140 at dinner.
Appetite remains excellent. Diet remains excellent.
Hydration remains a challenge. It’s so easy to either over or under hydrate her but, over a period of 24 hours, her body appears to retain and discharge fluid without causing problems (except for excessive leakage, which I now consider normal).
Her medication schedule remains the same as the day of her last appointment except that the “Iron Sorb” is no longer available up here so she now receives Niferex-150 twice a day, once at breakfast and once at dinner. I no longer give it to her an hour before her meal, as is normally prescribed, specifically to increase the potential that some of the iron will not be absorbed since this dose is somewhat higher than she was receiving previously.
Her blood pressure remains as follows: Systolic normally around 120, sometimes in the 130’s to 140’s, occasionally in the 150s to 160’s; Diastolic normally well below 80, usually in the mid 50’s to mid 60’s, very occasionally in the 70’s.
She remains a non-smoker. Oxygen consumption continues through the night at 1-2/lpm. During the day her use of oxygen is required when moving about a lot (exercising, going to the store, etc.) at 2/lpm. About once a week when she is very tired and mouth breathing I put her on 2 lpm when she is sitting.
Bowel movements remain regular, easy and of good volume and consistency (loaded with iron, of course), usually every 36 to 48 hours.
IN SUMMARY:
[Oh Wondrous FNP], I continue to appreciate your forthrightness with my mother and me at her last appointment. Now that I understand what is going on with her I have backed off my policy of anxiously pushing her to move, to drink and to follow my daily “inspirations” on how to “improve” her health. As a result she and I are both much more relaxed (more me than her...she has a naturally relaxed temperament that allows her to roll with the punches). It is wonderful to know that there is much I will not be able to prevent, thus, I needn’t worry as I did previously. This, above all, has been the most valuable of all the excellent advice and treatment you’ve provided. I am also very appreciative of the flexible and generous way you wrote her prescriptions. My anxiety over medication management has evaporated.
I expect to be receiving from the lab my copies of the test results over the next few days to a week or so (for the urinalysis). I’m not anxious. If you notice anything unusual or worrisome, please contact me. Otherwise, my expectation is that we will be coming in for a general appointment around June of this year.
I remember you telling me that you were in training for geriatric medicine. Let me tell you, [Oh Wondrous FNP], your touch and your abilities have, already, far exceeded the quality of much of the medical attention my mother has received in the past few years. I have no qualms about being normally scheduled to see you instead of [the attending physician] under any circumstances, as I trust that, when [the physician's] expertise is needed, you will know.
Update for Readers:
She has, within the last week or so, been moving a bit less and sleeping a bit more than mentioned in the above letter. We've been swept by the southern edge of a series of non-precipatory lows. I've observed that lows tend to slow her down.
Her blood sugar levels at lunch have begun to drop. A couple of times before I switched to breakfast readings this last Sunday I actually recorded some normal readings. My guess is that this is a sign that her diabetes is "going on vacation", as The Wondrous FNP predicted that it would. I am maintaining her glipizide dose but after a couple of weeks of exclusively morning readings I'll probably shift to a few weeks of three readings a day to see if I need to drop back on this medication. Of course, the extra movement may also be doing its job, as well. We'll see.
Of her own accord a few days ago when we had a particularly sunny, still, relatively warm day she walked out into our backyard to observe how it looks now that the hands of Mr. Everything are being applied and flora has begun to leaf out. "It's relaxing to look out here. We're lucky to have this place," she said. It is and we are. A day doesn't go by now but what she doesn't stand behind the Arcadia screen door and watch the goings on of the birds and animals in our back yard for a few minutes. I haven't convinced her yet to spend time out there but our weather is still bouncing between short periods of warmth and extended periods of coolness. I expect that when it becomes predictably warm during the day I'll be able to convince her to eat meals out there, wander around (under my watchful eye) and supervise my yard work.
A couple of days ago I talked at length with a nurse whose entire family, but primarily her mother, is involved in the care of her maternal grandparents, the grandmother of which has had to be admitted to a skilled nursing facility close to the family in Prescott Valley. Aside from gathering some very valuable information about which nursing homes in the area are the best and the problems surrounding those that are not very good, she treated me to a detailed history of the elder care in her family.
I remember this nurse telling me the following about her grandparents:
Grandfather: Currently 91; in excellent health until about a year ago when he suffered three heart attacks in one day (with no previous history of heart disease); now on oxygen 24 hrs/day; confined to a wheel chair; in obviously declining physical health although mentally sharp and aware.
Grandmother: Didn't catch her age; Type 2 diabetic (diagnosed in old age); her dementia was much like my mother's and she was not considered to be suffering from Alzheimers; about two years ago, though, her dementia took a sudden turn and she began displaying classic Alzheimer's symptoms; is laxative dependent; behavior is unpredictable and became so hard to handle that, in order to administer good care to the grandfather, the nurse's mother had her mother admitted to a nursing home; urinary incontinence considered to be primarily a result of the advanced dementia, which causes her to be unaware of when she has to urinate.
Background: Since these two people had divorced long ago, when they were required to live together again in order to receive their daughter's care their relationship was extremely contentious and they competed for attention from the caregiving daughter. As well, relationships with other family members, which were unpredictably dynamic at best, have greatly affected the daughter's ability to give care, since the daughter is constantly dealing with the backlash caused by other family members spotting her when she needs a break.
My impression is that I'm actually quite lucky in that, firstly, my mother and I have a life-long excellent relationship; secondly, I am not contending with elderly parents who are divorced and can't get along with each other nor with a history of contentious family relationships; my mother is not laxative dependent nor (normally) bowel incontinent; her senility is not following the classic patterns of Alzheimer's which include inappropriate and fierce displays of sexuality; paranoia regarding those with whom one is surroundeded; hiding of personal possessions; inappropriately divesting oneself of personal possessions (including giving away sets of furniture, stereo systems, jewelry and other items of value, as well as money to strangers, which the above mentioned grandmother did); extreme displays of verbally and physically abusive behavior toward loved ones.
The future, of course, is hazy at best. Who's to say whether my mother's dementia will advance to avocationally unmanageable proportions or that she will suddenly suffer a series of heart attacks, strokes or organ failure that will deliver a stark mark of quick decline upon her trek through Ancienthood? At least, now, I'm not worried about my ability to do the right thing by her. So, we take it minute by minute.
Today it's cool and cloudy. Yet another precipitous low is approaching which should deliver the bulk of its rain starting tonight. Mom's sleeping in after a late evening. Today would be a good day to do her hair. It'll keep her up for awhile, she loves the head massage and hair play it involves and, anticipating a cool day, I've promised to do some baking (probably scones) to warm up the house and keep the glow going within the cockles of her heart (sometimes I wonder, considering my mother's life long love of sugar, if the phrase, when applying to her, should be amended: "The cookies of her heart". We'll probably watch Thelma and Louise. She mentioned last night, during a commercial on one of the movie channels for it, that she'd, "...like to see that one, it looks interesting."
So today we'll be nesting. The Little Girl has alerted me that The Mom is up.
Later.
Tuesday, April 19, 2005
It must be morning...
...since I just finished inputting Mom's recent lab work. The results can be reached as follows:
Blood Test (CBC & BMP) Draw Date: 4/13/05
Urinalysis Collection Date: 4/13/05
We're getting the southern edge of a storm. It's terribly windy and colder than it's been lately. Mom's taking a loooooong nap. I've been checking up on her periodically. She's breathing easily, looking good in her sleep, so I'm only experiencing a smidgen of anxiety. She hasn't slept this long in the afternoon for several weeks.
I was finally able to procure her an Easter ham on Sunday, so, yes, you guessed it, almost every meal since Sunday dinner has included ham: Ham and eggs for breakfast; ham steak and a modified Cobb salad with lots of ham substituting for about half the normal load of vegetables for dinners; ham on crackers with cheese for lunch. Tonight we'll have bean and ham soup with garlic cheese toast. When I picked up the herb bread for the garlic cheese toast I also picked up a special surprise: A dessert - tangy lemon squares. We haven't had dessert in a long time. I know that especially since she's awfully tired today she'll be thrilled.
Yeow! The Mom's up. Time to start the third part of her day.
Later.
Blood Test (CBC & BMP) Draw Date: 4/13/05
Urinalysis Collection Date: 4/13/05
We're getting the southern edge of a storm. It's terribly windy and colder than it's been lately. Mom's taking a loooooong nap. I've been checking up on her periodically. She's breathing easily, looking good in her sleep, so I'm only experiencing a smidgen of anxiety. She hasn't slept this long in the afternoon for several weeks.
I was finally able to procure her an Easter ham on Sunday, so, yes, you guessed it, almost every meal since Sunday dinner has included ham: Ham and eggs for breakfast; ham steak and a modified Cobb salad with lots of ham substituting for about half the normal load of vegetables for dinners; ham on crackers with cheese for lunch. Tonight we'll have bean and ham soup with garlic cheese toast. When I picked up the herb bread for the garlic cheese toast I also picked up a special surprise: A dessert - tangy lemon squares. We haven't had dessert in a long time. I know that especially since she's awfully tired today she'll be thrilled.
Yeow! The Mom's up. Time to start the third part of her day.
Later.
Monday, April 18, 2005
Well, fancy meeting you here!
I've got labs from her first "monthly" draw since January 21st, taken last Wednesday. Very nice numbers. I'm going input them forthwith but probably won't complete them until tomorrow morning. In case you're curious, her hemoglobin was 11.2! Excellent! At Mesa's elevation, according to the last normal range (ranges, as you may know, are refigured occasionally-to-frequently per lab depending on all results obtained within a particular time period per area, gender and age and on the make of the tests used), 11.2 is within .3 of falling into normal range. As a neurologist informed me during her last hospital visit, because of her advanced age, the fact that much of the last 24 years has been spent at Mesa elevation and that most of her life has been spent at Mesa elevation or below it would be unusual for her body to adjust to normal ranges for 6000' elevation. Which is fine. Several of her other readings, while slightly out of normal range for Prescott elevation, are within normal range for Mesa elevation. Her monthlies now include a B(asic)M(etabolic)P(anel, to keep an eye on her electrolytes and BUN (which remains high) and a urinalysis, which came back clear.
I'm continuing modified grunt work, am not taking a vacation from caregiving, just a vacation from reporting on it, am continuing to take stats, although I've not been recording her bowel movements but those remain regular, easy and well formed [Eeww, do you have to be so specific? Yes, Virginia, there really is a good reason to notice the detail of her bowel movements.]
I've gotten her to begin therapy exercises, again, easy and light and occasional. I do not harrass her anymore if I can't convince her within a few minutes. Things are going well. I'm pleased. Mom's in good spirits. I'll be reporting more...
...sooner than later.
I'm continuing modified grunt work, am not taking a vacation from caregiving, just a vacation from reporting on it, am continuing to take stats, although I've not been recording her bowel movements but those remain regular, easy and well formed [Eeww, do you have to be so specific? Yes, Virginia, there really is a good reason to notice the detail of her bowel movements.]
I've gotten her to begin therapy exercises, again, easy and light and occasional. I do not harrass her anymore if I can't convince her within a few minutes. Things are going well. I'm pleased. Mom's in good spirits. I'll be reporting more...
...sooner than later.
