One Step at a Time

A. Mark Clarfield, MD, Chief of Geriatrics, Soroka Hospital, Beer-sheva, Israel; Sidonie Hecht Professor of Geriatrics, Ben-Gurion University of the Negev, Beer-sheva, Israel; Staff Geriatrician of the Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, QC.

When I lived in Montreal I was asked to consult on an 89-year-old Chinese man who had suffered his first cerebrovascular accident four weeks earlier. After three days of stabilization in an acute-care medical ward, he had been transferred to a rehabilitation hospital for physiotherapy.

“Mr. Chan” returned to our acute-care institution after three weeks at the rehabilitation facility. A note explained that because the patient had stopped improving, he no longer needed the bed in that hospital facility. What he now required, we had been told, was an acute-care hospital bed where he could await transfer to a long-term bed--something that might, in our situation, take over a year!

When I went up to his ward it took me several minutes to find Mr. Chan because he had gone for a walk with his wife to a solarium 100 yards away in another wing of the hospital. After hunting down my quarry, I asked him to return to his room. As he did so, I observed his gait while he negotiated the crowded corridor with the aid of a walker. His elderly wife was by his side, but I noted that she was not physically supporting him in any way.

Because it was clear to me that he spoke little English, I greeted him in Mandarin, “Nee how.” (I know how to say hello in 27 languages. Although I cannot say much more than that in most of them, saying hello really does help break the ice.) He looked quizzical, and I asked him, “Hong Kong? Beijing?” When he answered, “Hong Kong,” I knew what kind of interpreter to call upon.

Our hospital admitting service soon sent around one of the laboratory technicians who spoke fluent Cantonese, and for the next half-hour she acted as my able translator.

Q. What brought you to the hospital?
A. Mr. Chan: I had a stroke. I was transferred to another hospital, but they sent me back here.

Q. Why?
A. Mr. Chan: Because they said that they could not help me anymore.

Q. What do you want to do?
A. Mr. Chan: I want to go home to be with my wife.

Q. What’s stopping you?
A. Mr. Chan: Our bedroom and washroom are on the second floor of our house, but I can’t get up there. After my second week in the convalescent hospital I was sent home for a weekend, but when I had to urinate I could not get up the stairs to the bathroom.

Q. What happened?
A. Mr. Chan: I wet my pants, and I was very ashamed in front of my wife. This had never happened to me before.

I was beginning to get the picture. I excused myself and called the physician in charge of the case at the rehabilitation hospital. He explained that Mr. Chan had been sent back to us because he had “plateaued,” and that “the family does not want him home; they want him placed in a nursing home.”

I asked whether the doctor had access to an interpreter to talk with this essentially unilingual Chinese couple. He explained that he had not, but that he had spoken with a daughter on the phone, who had expressed her parents’ wishes.

Returning to the older couple, I repeated the other physician’s version of the story. They looked at me with disbelief in their eyes. “No, not at all,” exclaimed the woman. “If only I can get my husband up the stairs twice a day, we can take care of him at home. I don’t want him placed. Not at all!”

My mind was made up. I called in our physiotherapist, occupational therapist, and social worker. Together with our nurses, we got the man up and walking each day. With the aid of the interpreter, we also taught him how to negotiate stairs under his wife’s watchful supervision. Six weeks later, he returned home.

What lessons can be drawn from this case? First, one must not rush older rehabilitation candidates. Stroke rehabilitation is a slow process at any age, but the older victim requires more time than a younger person with the same level of disability. To pronounce that the patient had “plateaued” after three weeks was simply not appropriate. Tincture of time, applied p.r.n., was required here.

Second, although not viewing the world through rose-coloured glasses, the physician must be optimistic and must transmit this optimism to the patient. If you are not enthusiastic about the chances of recovery, why should a patient contradict you? Older people, especially immigrants, still maintain an inflated sense of the doctor’s omniscience. Why not use this psychological “laying on of hands” to the patient’s benefit, especially when the prognosis is not clearly poor?

Third, one must recognize when the forecast is not dismal. In this case, Mr. Chan had suffered no previous cognitive deficit, was otherwise in reasonably good health, and had a supportive wife who was certain she did not want to place him in a long-term care facility. It helped that he was an eager student once the “teachers” entered the classroom. The fact that I could not find him in his room that first day because he and his wife had gone on their own Long March made me wonder why the patient had been sent back to us from the rehabilitation hospital.

Fourth, one should use the other members of the health care team. As a physician, I thought that the patient might be able learn to climb stairs. The physiotherapist not only confirmed this impression, but she actively and expertly taught him his steps. The occupational therapist made a home visit to ensure that any aids that could help Mr. Chan would be in place by the time he returned home.

Finally, one must talk with the patient. Without an intelligent and capable interpreter, nothing could have been done with this particular patient and family. This fact may seem obvious, but it is amazing how often the all-important history is taken in a perfunctory manner. In Mr. Chan’s case, carefully communicating with the patient meant the eventual difference between an independent life at home and an inappropriate long-term institutionalization. Apart from the benefit to the patient and his family, consider the health care dollars saved by such a relatively short but intensive period of rehabilitation.

The main difference between young and old is the older person’s loss of reserve--physiological, psychological, and sociological. However, just because your patient is older does not mean that he or she cannot benefit from attempts at rehabilitation. On the other hand, the physician experienced in the care of older adults will not want to squander precious recources on a poor rehabilitation candidate. Knowing the difference, having faith in your judgment, and pushing the patient and family as far and as fast as they want to go will reap benefits not only for the medical system but for the patient and the family, as well as for your sense of satisfaction with a difficult job well done. When it comes to rehabilitating older adults, we would do well to remember the old Chinese saying: “A journey of 10,000 li must begin with a single step.”