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"How long has he been like this?"

Home visit. I only do home visits for hospice or the super frail elderly where the family can't even get them in the car.

He is 87. He's in pajamas. He is in a chair, zoned looking, drooling a little. I am impressed that his 84 year old wife could get him to a chair. She weighs about 2/3 of what he is and he's well over 6 feet, though gaunt.

"Well, he," she swallows. No tears, I can see the effort. "Thank you, doctor, for coming out."

He missed a visit three weeks ago. When people are getting frail, I ask them to come in every 3 months. I want to know when they can't make it. Also, the end stage of dementia is when people's neurons melt until they return to the womb. They stop eating. They don't need to eat. It's best to let them.

The wife is amazing. She is clean, dressed and the house is cluttered but not a mess/death trap/full of rats. They are not hoarders. The husband is also clean though not dressed. He is not clearing his airway and now has frothy bubbles coming from his mouth. His wife meticulously wipes his mouth. He still sounds like his lungs are full of fluid, but it is upper airway, not asthma. He just doesn't remember to cough.

Finally his body coughs, and the airway clears. The cough racks him and he moves hardly any air. I look at my notes. Fifty years of cigarettes, quit at age 67. Twenty years ago.

"What did he smoke?" I ask, as I put the pulse ox on his finger. He doesn't move at all. 02 sat at 91, heart rate 56. Bradycardia, but the cardiologist won't care as long as he's not "symptomatic". And would we put him through surgery? Hell, no. His beta blocker was stopped two years ago.

"Unfiltered camels." she says.

Blood pressure should be taken standing, but well. Sitting his is at 106/58. I look at the meds.

"We could stop the hydrochlorothiazide."

"Then his legs swell."

His legs already are swollen. 1+ to the knee, which is pretty good all things considered. Let's see, dementia, coronary artery disease, mild to moderate heart failure, emphysema, he's been diabetic for 20 years, last lab work a year ago. I should examine all his skin, look for pressure sores, but the house and his cleanliness tell me how well his wife is taking care of him.

Speaking of zombies, she looks worse than he does. Exhausted. Grey. Her hands are trembling a little. She has lost weight as well.

"You have two children, right?"

She nods. One is a university professor of anthropology in Hamburg, Germany. The other is an engineer and lives 3000 miles away. There are 4 grandchildren and one great grandchild.

"Our son came at Christmas. Our daughter came at Thanksgiving. They are very busy."

Yes, I know. "Are you in a church?" I say gently.

She is looking out the window now. I see the flash reflecting off her cheek. "No."

"I can get home health but they do not do round the clock care. You need people here at night so you can sleep. Or he needs to be in an advanced care unit." He has multifactoral dementia. Small vessel disease, alcohol, tobacco, then the progression of Alzheimer's on top of that. His PhD doesn't matter any more.

"I promised we would stay home. And he hates other people coming in. I promised."

"You will die before him if you continue this way." I do have a prescription pad. "You can afford night time help?"

"Yes. And we have long term care insurance."

For a moment there is a light in his eyes. He gropes and she comes and takes his hand. He relaxes again.

"All right. I will order home health. They will send a team, not all on the same day. A nurse, social work, occupational therapy to help with equipment and physical therapy. Maybe a bath aide. How much weight has he lost?"

"I feed him!" she says.

"He is reaching the stage where he forgets to eat." I say gently. "If he doesn't want to eat, you should let him not eat."

She looks down.

"Home health will weigh him. When he is losing weight, that is end stage dementia. He will qualify for hospice. I can see that he has lost some weight already." I touch her shoulder. "I will help you keep him home. He is going."


I write on the prescription pad. "You have to have a minimum of four hours of help a day, when someone else is watching him. How have you been getting groceries?"

"My neighbor." she says.

"Is he up and wandering at night?"

"Not every night."

Most nights, I'll bet. "You have to have three nights where you can sleep and someone else is here. Three nights minimum. And I would like you to go stay at a friend's one night a week, so that you really rest."


"I will be back in a month." I have written when SHE needs the time on the prescription. Orders. "You need a clinic visit as well. Within a month."

She doesn't say anything else until I leave. Whisper. "Thank you, doctor."

This is a fictional pair of patients. But I see variations of this over and over. With husbands doing the care, too, or an adult "child".