Hygiene question.

[mjl1717]

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What do you say? If a friend/patient comes to you and states:

"My 89 year old mother with mild dementia will not take a shower or will only take a shower every 2-3 weeks. She just wants to "sponge off". [This has been going on for perhaps 3-4 months]

Talking and explaining the benefits of hygiene to her do not seem to have much effect. Any thoughts on this?

 

[erg923]

Not really sure what your question is? Suffice to say this is how most all humans lived for thousands and thousands of years,

 

[robellis]

Not really sure what your question is? Suffice to say this is how most all humans lived for thousands and thousands of years,

He’s asking what to say to this person. OP you just tell them that older people like to take less and less showers but you have to coax them using a variety of behavioral techniques (similar to kids/dogs) to get them to shower.

 

[birchswing]

What do you say? If a friend/patient comes to you and states:

"My 89 year old mother with mild dementia will not take a shower or will only take a shower every 2-3 weeks. She just wants to "sponge off". [This has been going on for perhaps 3-4 months]

Talking and explaining the benefits of hygiene to her do not seem to have much effect. Any thoughts on this?

What are the benefits?

 

[Crayola227]

This is actually a lot more complex than it seems on the surface.

I think we would need to understand a lot more about the 89 yo person's health to make any kind of judgement. It makes a big difference if she has schizophrenia, dementia, or is generally quite frail, for example. Also it depends on how effective her spongebaths are, and what shape her skin and etc is in as a result of her bathing habits.

If her skin is adequately cared for and she's at a great risk of falls, then her current regimen might actually be best from a safety perspective.

If her current regimen is not adequate for the health of her skin, the answer still might not be more frequent showers. Maybe she prefers baths but a bath is not available? There's a lot of questions and things to consider here before we declare this person is right and she needs to shower more. And if she doesn't have any health issues from her habits besides some BO, well again there are ways to deal with that and a shower is not the only solution, AND if it's a hypothetical but her current habits are enough to maintain her current health, again, not sure why arguments about hygeine health should be the end all be all to sway someone's actions.

Just trying to make a case "you need to shower more because if you don't this is what bad hygeine can do" absolutely is not sufficient because it doesn't address any legit reasons for her not to use a shower or to use other methods of maintaining hygiene.

If dementia or schizophrenia is the issue, depression, or losing track of days etc, then again, this approach may not be best.

So on the surface considering all this, medically I can't just immediately side with someone's argument that someone else needs to shower more.

 

[mjl1717]

He’s asking what to say to this person. OP you just tell them that older people like to take less and less showers but you have to coax them using a variety of behavioral techniques (similar to kids/dogs) to get them to shower.

Thank you! This is what I was thinking in the crevices of my brain. Just needed to hear someone else express it. I just do not know if its appropriate to say. " I will not take you to Atlantic City." "Or I will not take you to the movies if you do not shower?"

 

[mjl1717]

What are the benefits?

1) Possibly preventing a skin disorder.
2) After a good shower one may experience renewed vitality.

 

[Crayola227]

1) Possibly preventing a skin disorder.
2) After a good shower one may experience renewed vitality.

Or one can bring about skin issues, or one may feel exhausted or faint or fall. As I said, more complex.

 

[Crayola227]

He’s asking what to say to this person. OP you just tell them that older people like to take less and less showers but you have to coax them using a variety of behavioral techniques (similar to kids/dogs) to get them to shower.

This is terrible advice for a lot of reasons I've outlined. It's not clear "coaxing" more showers is best for this person or all elderly. Acting like the way to treat or modify elderly behavior by infantilizing them or treating them like animals is also a pretty disgusting and inappropriate approach.

 

[robellis]

This is terrible advice for a lot of reasons I've outlined. It's not clear "coaxing" more showers is best for this person or all elderly, and acting like the way to treat or modify elderly behavior by infantilizing them or treating them like animals is also pretty disgusting.

Wtf…

 

[Crayola227]

The phrasing definitely reinforces a view of elderly that is problematic and inappropriate. You would never see a geriatrician say something like this.

The approach to dealing with the elderly should always be to recognize their autonomy as an adult in this society to fullest extent possible. There are approaches to dealing with the elderly, but I would not model them on dealing with children or dogs.

And I would not personally want to be treated or have a loved one treated by someone I heard use that kind of language or didn't recognize how inappropriate it is.

 

[robellis]

The phrasing definitely reinforces a view of elderly that is problematic and inappropriate. You would never see a geriatrician say something like this.

The approach to dealing with the elderly should always be to recognize their autonomy as an adult in this society to fullest extent possible. There are approaches to dealing with the elderly, but I would not model them on dealing with children or dogs.

And I would not personally want to be treated or have a loved one treated by someone I heard use that kind of language or didn't recognize how inappropriate it is.

What is your specialty?

 

[birchswing]

1) Possibly preventing a skin disorder.
2) After a good shower one may experience renewed vitality.

The vitality I guess I can see. But we don't usually push people to experience vital experiences.

The skin thing is a good point, except that she already expressed she prefers sponge baths, which seems very reasonable at age 89. Every time you use the toilet you are engaging in partial bathing to some extent, so that takes care of part of the issue. And sponging takes care of the rest. As long as you're getting some blood flow to the skin, removing dead skin every once in a while with a sponge, and have clean clothes and sheets, I don't think there's a lot of difference?

Plus showering is exhausting. I was thinking it was higher on the METS list. I just looked it up and it's actually low. I have POTS and it's one of the most exhausting things I do so I figured it was up higher. I have to lie down after showering for a while. It's kind of the opposite of revitalizing for me. Standing in one place with blood pooling in the legs, and the combine that with your arms above your head, plus warm water dilating vessels. It's easier for me to go for a brisk walk than to shower. But I'm a bit unusual having POTS, but maybe not that different from an elderly person.

 

[mjl1717]

This is actually a lot more complex than it seems on the surface.

I think we would need to understand a lot more about the 89 yo person's health to make any kind of judgement. It makes a big difference if she has schizophrenia, dementia, or is generally quite frail, for example. Also it depends on how effective her spongebaths are, and what shape her skin and etc is in as a result of her bathing habits.

If her skin is adequately cared for and she's at a great risk of falls, then her current regimen might actually be best from a safety perspective.

If her current regimen is not adequate for the health of her skin, the answer still might not be more frequent showers. Maybe she prefers baths but a bath is not available? There's a lot of questions and things to consider here before we declare this person is right and she needs to shower more. And if she doesn't have any health issues from her habits besides some BO, well again there are ways to deal with that and a shower is not the only solution, AND if it's a hypothetical but her current habits are enough to maintain her current health, again, not sure why arguments about hygeine health should be the end all be all to sway someone's actions.

Just trying to make a case "you need to shower more because if you don't this is what bad hygeine can do" absolutely is not sufficient because it doesn't address any legit reasons for her not to use a shower or to use other methods of maintaining hygiene.

If dementia or schizophrenia is the issue, depression, or losing track of days etc, then again, this approach may not be best.

So on the surface considering all this, medically I can't just immediately side with someone's argument that someone else needs to shower more.

Just to give more info:

She is an fragile, 89 yo female. Her children are no longer directly part of household. And only occasionally visit her. Her spouse passed away 11 years ago. She has an aid who helps with ADLs 8 hours per day. Hx of mild anxiety. Hx of severe insomnia. Hx of mild depression She complains of fatigue even after attempted sleeping. Does very minimal exercise. Lost 20lbs in the last year because of decrease appetite. But will eat 3 small meals per day. She goes to her routine doctors appointments. She has controlled HTN, and Hyperlipedemia. Has developed stage 1 bed sore. Most of the time is spent watching TV or watching Youtube. Lastly she is on 11 meds, but 200mg Trazadone may not treat her insomnia.

 

[birchswing]

Just to give more info:

She is an fragile, 89 yo female. Her children are no longer directly part of household. And only occasionally visit her. Her spouse passed away 11 years ago. She has an aid who helps with ADLs 8 hours per day. Hx of mild anxiety. Hx of severe insomnia. Hx of mild depression She complains of fatigue even after attempted sleeping. Does very minimal exercise. Lost 20lbs in the last year because of decrease appetite. But will eat 3 small meals per day. She goes to her routine doctors appointments. She has controlled HTN, and Hyperlipedemia. Has developed stage 1 bed sore. Most of the time is spent watching TV or watching Youtube. Lastly she is on 11 meds, but 200mg Trazadone may not treat her insomnia.

What do the 11 meds do? That's a lot.

Does she have heart failure and/or an arrhythmia?

 

[nexus73]

What do the 11 meds do? That's a lot.

Does she have heart failure and/or an arrhythmia?

I think that’s average these days

 

[mjl1717]

No hx of heart disease, but she has severe fatigue, recently Dxed with hypothyroidism. **Very minimal short term memory. She is on Norvasc 5mg bid Olmesarten medroxil 20mg, triamterene/ HCTZ 37.5/25, isosorbide mono nitrate ER 30mg prophylactically, crestor 10m, ASA 81 mg, donepezil 10mg, potassium 10 meg, Effexor XR 150mg, Levothyroxine 50mcg.
As mentioned Trazadone 200mg at bedtime may not work . All meds are QD except the Norvasc which is bid. Crestor was recently D/C ed because the AST was 82 and the ALT was 131. Thank you guys. Any more thoughts on the hygiene part?? Or is it one of those unfortunate entities where one reluctantly has to say "let it be"??

Also I must say: ** I am aware that In the USA at times little respect nor conscientiousness is given to the elderly. Compared to India and China the elderly are more revered!

 

[robellis]

No hx of heart disease, but she has severe fatigue, recently Dxed with hypothyroidism. She is on Norvasc 5mg bid Olmesarten medroxil 20mg, triamterene/ HCTZ 37.5/25, isosorbide mono nitrate ER 30mg prophylactically, crestor 10m, ASA 81 mg, donepezil 10mg, potassium 10 meg, Effexor XR 150mg, Levothyroxine 50mcg.
As mentioned Trazadone 200mg at bedtime may not work . All meds are QD except the Norvasc which is bid. Crestor was recently D/C ed because the AST was 82 and the ALT was 131. Thank you guys. Any more thoughts on the hygiene part?? Or is it one of those unfortunate entities where one reluctantly has to say "let it be"??

Also I must say: ** I am aware that In the USA at times little respect nor conscientiousness is given to the elderly. Compared to India and China the elderly are more revered!

I’m confused how do you have all this information if your friend just randomly asked you this question in passing

 

[birchswing]

Does she have Alzheimer's (the donepezil)? Also hard not to believe she has heart disease with those meds . . . but heart disease is a different disease than arrhythmia/heart failure, which I was curious if she had been checked for as a cause of fatigue at that age but looking at the meds it sounds like she has a lot of reasons to be fatigud. I'm not a doctor. That's a lot of meds, and it sounds like she is having a lot of the health issues an 89 year old would have, and I'd say yes let it be regarding showering.

Edit: My mistake. I had been told at some point heart disease specifically refers to CAD. I grew curious after thinking how generic the term is and see it is a more general term.

 

[mjl1717]

Does she have Alzheimer's (the donepezil)? Also hard not to believe she has heart disease with those meds . . . but heart disease is a different disease than arrhythmia/heart failure, which I was curious if she had been checked for as a cause of fatigue at that age but looking at the meds it sounds like she has a lot of reasons to be fatigud. I'm not a doctor. That's a lot of meds, and it sounds like she is having a lot of the health issues an 89 year old would have, and I'd say yes let it be regarding showering.

Edit: My mistake. I had been told at some point heart disease specifically refers to CAD. I grew curious after thinking how generic the term is and see it is a more general term.

Yes, mild Alzheimer.

 

[SpinDktr]

It is more likely mild to moderate or moderate dementia at this point. What you are describing is loss of ADL's consistent with advancing dementia. Although 8 hours of personal attendance per day may seem like a lot, it may not be enough to keep her safe or tend appropriately to her needs. Often times people have incontinence at this stage where showering can also help with skin issues. What you described is a minimal snapshot; a geriatrician or geriatric trained provider would be of more help, as these cases always get complicated quickly. Also, many ALF's frequently do a better job at encouraging ADL's, but not always. Just a few thoughts.

 

[Liquid8]

This is tricky. Not bathing regularly is a common problem in our senior citizens, and there are many reasons why more regular showering isn’t an option – you have to consider overall mobility, falls risks, i.e. do they need assistance getting in/out of baths and showers. There may be other things to consider. - what is their grip strength like or is there an issue with the shower tap tightness.

If in a care facility, a sponge bath may also be more dignified, as the carers may only uncover parts that are being washed each time. Obviously it’s not a replacement for a proper bath/shower, but sometimes you have to compromise.

 

[mjl1717]

I’m confused how do you have all this information if your friend just randomly asked you this question in passing

It is more likely mild to moderate or moderate dementia at this point. What you are describing is loss of ADL's consistent with advancing dementia. Although 8 hours of personal attendance per day may seem like a lot, it may not be enough to keep her safe or tend appropriately to her needs. Often times people have incontinence at this stage where showering can also help with skin issues. What you described is a minimal snapshot; a geriatrician or geriatric trained provider would be of more help, as these cases always get complicated quickly. Also, many ALF's frequently do a better job at encouraging ADL's, but not always. Just a few thoughts.

Thank you. I assume ALF stands for assisted living facility.

 

[SpinDktr]

Yes, ALF is assisted living facility. ALF's in our area vary widely from $3500/mo to $5500/mo usually. We also have memory care units in this area that vary widely, but are regulated under ALF state regulations. Memory care facilities in this area usually go for $4000/mo to $8500 or more. The cost of a caregiver at 8 hours/day is in this ballpark I am sure. But for 16 hours a day, people can wander, start fires, etc. Dementia is a difficult stage of life for families and the patient.

 

[birchswing]

Yes, ALF is assisted living facility. ALF's in our area vary widely from $3500/mo to $5500/mo usually. We also have memory care units in this area that vary widely, but are regulated under ALF state regulations. Memory care facilities in this area usually go for $4000/mo to $8500 or more. The cost of a caregiver at 8 hours/day is in this ballpark I am sure. But for 16 hours a day, people can wander, start fires, etc. Dementia is a difficult stage of life for families and the patient.

Medicaid pays 100%, I believe. You have to immiserate yourself (give all assets to family or exhaust them). Or can use Medicare, which pays a bit, can't remember how much, but they at least negotiate the base rate down.

 

[SpinDktr]

In Wisconsin, Medicaid will pay for you to stay in an ALF, but only after you have exhausted the majority of your assets. In addition, Medicaid will only pay so much; they will never pay $8500/mo for a facility. They negotiate contracts, and the pay is pretty poor. Some of the really "nice" ALF's will actually kick you out once you exhaust your assets. Some will take you if you can at least pay for 2 years. The situation is similar in most other states from what I gather.

 

[Crayola227]

Medicaid pays 100%, I believe. You have to immiserate yourself (give all assets to family or exhaust them). Or can use Medicare, which pays a bit, can't remember how much, but they at least negotiate the base rate down.

Common misunderstanding that hurts many people.

You have to have made the gifts BEFORE you have any condition that could reasonably lead you to need long term care or Medicaid, and they look back 3 years. So the time to gift anything is when you are still well and have no major health issues. If you wait to get sick and you need the care, you'll be screwed. They can and will deny you care and coverage

 

[Crayola227]

It seems kinda sad for a lady to have Alzheimer's and to be this old and frail and have so many issues and so much difficulty with ADLs that she has 8 hrs a day of care, and for someone to be so focused on her having one more thing on her plate, and one that reasonably is actually likely quite a burden from a physical standpoint. She needs to bathe a certain amount for her health, but she also needs to balance it against all the numerous issues.

Is the person who wants her to bathe more, willing and able to safely to bathe her? Would she feel comfortable having this person's assistance to even do so?

Getting older, and frankly having one's body slowly disintegrate to the point of death, as well as losing one's mental faculties is not glamorous. She only has so many resources it sounds like internal and external. Some things have to be prioritized and others may fall to the side.

 

[Ironspy]

sounds like someone’s asking for medical advice

 

[michaelrack]

why is she taking norvasc 5 bid instead of 10 daily? and you dont give isosorbide prophylactically to someone without coronary artery disease.

 

[michaelrack]

I would stop crestor unless she has documented coronary artery disease

 

[michaelrack]

with the decreased appetite, would strongly consider stopping aricept

 

[birchswing]

Common misunderstanding that hurts many people.

You have to have made the gifts BEFORE you have any condition that could reasonably lead you to need long term care or Medicaid, and they look back 3 years. So the time to gift anything is when you are still well and have no major health issues. If you wait to get sick and you need the care, you'll be screwed. They can and will deny you care and coverage

There's a popular call-in radio advice show with a psychotherapist (I guess . . .) and a very common source of stress is children taking care of their parents into old age. And it drives me crazy every time this therapist (I guess . . .) says that they have no moral responsibility to be there in person and should just hire 24 hour care. Completely detached from the reality of what the cost is, or at least what that cost means for most people.

 

[Mass Effect]

Does she have Alzheimer's (the donepezil)? Also hard not to believe she has heart disease with those meds . . . but heart disease is a different disease than arrhythmia/heart failure, which I was curious if she had been checked for as a cause of fatigue at that age but looking at the meds it sounds like she has a lot of reasons to be fatigud. I'm not a doctor. That's a lot of meds, and it sounds like she is having a lot of the health issues an 89 year old would have, and I'd say yes let it be regarding showering.

Edit: My mistake. I had been told at some point heart disease specifically refers to CAD. I grew curious after thinking how generic the term is and see it is a more general term.

Aren't you a patient who's reading the forum? I appreciate that you said you're not a doctor, but that sentence should be expanded when you're giving advice. I've said it before, I think it's very confusing and borderline unethical for you to be giving advice without prefacing it with the fact that you're not a doctor, NP, psychologist, or med student. When people ask questions on this forum, they're asking their peers, not patients. The reason that's important is that they're looking for expert guidance and if that's not what you're giving, it should be stated.

 

[mjl1717]

why is she taking norvasc 5 bid instead of 10 daily? and you dont give isosorbide prophylactically to someone without coronary artery disease.

1) To attempt to ensure 24 hr control of her bp. (she recently had 5 day hospital admission for dizziness due to bp flare up, Norvasc bid was added near discharge) But her bp was acutely lowered in hospital with the "dinosaur" Clonidine. Which stopped the dizziness, and allowed her to sleep! Ironically, allowing her to at times appear more vibrant.

2)*I was under the impression most folks over age 50 have CAD. Even if no symptoms. (no one can pinpont the cause of her fatigue) I believe her cardiologist was proactive instead of reactive with isosorbide mononitrate ER 30mg.

3) Thank you very much guys!! I recently heard she took a shower!! I really appreciate every ones feedback!

 

[birchswing]

Aren't you a patient who's reading the forum? I appreciate that you said you're not a doctor, but that sentence should be expanded when you're giving advice. I've said it before, I think it's very confusing and borderline unethical for you to be giving advice without prefacing it with the fact that you're not a doctor, NP, psychologist, or med student. When people ask questions on this forum, they're asking their peers, not patients. The reason that's important is that they're looking for expert guidance and if that's not what you're giving, it should be stated.

Are you still sure it's a peer who is asking for advice?

No one can pinpoint cause of fatigue . . . (insomnia, 89 years old, heart disease, multiple BP meds).

Ironic that sleep increased vibrancy . . .

Most adults have CAD . . . (yes I know everyone has plaque like everyone has photoaging but it's not the same as CAD)

Proactive drug against non-existent angina?

If I had gone to medical school, could have I given a better "peer to peer"? Or might I be deluded into not being able to recognize when someone is not a doctor. At least I'm up front about it.

If this is a doctor, well then . . .

 

[michaelrack]

Are you still sure it's a peer who is asking for advice?

No one can pinpoint cause of fatigue . . . (insomnia, 89 years old, heart disease, multiple BP meds).

Ironic that sleep increased vibrancy . . .

Most adults have CAD . . . (yes I know everyone has plaque like everyone has photoaging but it's not the same as CAD)

Proactive drug against non-existent angina?

If I had gone to medical school, could have I given a better "peer to peer"? Or might I be deluded into not being able to recognize when someone is not a doctor. At least I'm up front about it.

If this is a doctor, well then . . .

I agree with birchswing regarding the CAD/isosorbide. Isosorbide is for symptom control, not for prophylaxis. It does not prolong life or reduce cardiac events. her pcp should strongly consider stopping it, especially given her recent dizzyness. And the half life of norvasc is over 24 hrs, no need to give twice a day.

 

[Mass Effect]

I skip responding on almost every single thread. Because of my position and also because I don't have anything to say.

As a non-doctor, I believe it's OK to let a person who will die in the foreseeable future to not be forced to take a shower. Or really do whatever else they want or don't want to do.

Is "I won't take you to Atlantic City if you don't take a shower" a medical problem? There are a lot of people in Atlantic City who haven't showered (a little levity).

I find it interesting I'm the only one who teased out enough background on this case to give a clearer picture of what is going on.

I don't have to be a doctor to know that this person has CAD despite a doctor being in denial that she does (that in itself could cause fatigue and showering won't help the fatigue caused by CAD).

I don't have to be a doctor to know that weight loss and being 89 means life is winding down.

This is not about a shower.

This is about someone who is obviously very close to someone who is not accepting what is happening.

Maybe an expert should tell the OP that.

I've been around people dying at this age, and you know who isn't there? Doctors. There are hospice workers. There are nurses. There are neighbors and volunteers.

This is about the course of human life.

If you took an advanced course in showering in medical school, I am afraid it is wasted on accepting that people die. It's very sad. I wish it didn't happen this way. I know about bed sores. I think everyone knows about bed sores. I know about skin health. I think everyone knows something could theoretically go wrong without enough hygiene, but I also think everyone knows at 89 something is going to go wrong one way or another.

Someone changed my profile thing. It used to say non-doctor. I can't edit it myself now. I don't know how much clearer to make it. I usually try to go out of my way to say it repeatedly, but when it comes to showering and 89 year old, I guess I slipped up and didn't mention it again. Or didn't mention it enough.

My very non-medical opinion is to not coax a person to shower who has found other means (sponge bathing) and has found ways to enjoy their time (the OP mentioned they enjoy watching TV and YouTube).

People have been helping people to live out their last days long before modern medicine, long before showers existed. I wish her peace, and some good TV shows.

A how to question on teaching the "benefits of hygiene" for an 89 year old with severe health conditions are not for the benefit of the patient. It's a defense mechanism for the benefit of the person who is trying to get out of the present moment and see a longer future than there is. I would think psychiatric advice would be about getting back in the present moment.

I should be clear they didn't teach us that in high school, either. Just an uneducated opinion.

The question could be how do I get my 89 year old relative to stop smoking. What does it matter? It's not a psychiatric question. People choose how they want to live and die.

Usually when someone posts a critique of my position like this I get shadow-banned for a while, maybe this time permanently, who knows. I usually don't respond, but felt like rolling the dice as they do in Atlantic City.

If I am, and this is the last thing I get to post (which could be as I get harassed more and more and more haphazardly): If you're saying I shouldn't write a medical opinion (and I don't think I have), can you honestly say the question posed was a medical question?

To answer your question, I am that krazy kook patient you've heard about who doesn't think a trip to Atlantic City should be held over Mother's head over a shower and who doesn't think there is such a thing as a peer consult medical answer to this situation, which is not so much a specific medical situation as it is a life situation that everyone if they are lucky enough to reach 89 will face.

I'll get even kookier (I'm not an endorser of Byron Katie, but this is particularly apropos):

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Yeah, it actually is a medical question and the default is that we assume patients aren't giving suggestions here, so it would be helpful if you would preface your suggestions with the fact that you're a patient and not a medical/healthcare professional.

 

[birchswing]

Yeah, it actually is a medical question and the default is that we assume patients aren't giving suggestions here, so it would be helpful if you would preface your suggestions with the fact that you're a patient and not a medical/healthcare professional.

As I previously stated, my status said that until it was changed (out of my control—I can longer edit it, but someone wrote for me "non-medical"—it was previously more specific), and as you said yourself, I did state in this thread that I am not a doctor, as well. I can attempt to expound on that more in the future if this situation comes up again, but I rarely offer advice, and to the extent you think advice about holding a trip to Atlantic City as a bargaining chip over someone close to the OP based on whether they take a shower or not is a medical question when they are in denial about their health status, I think I offered enough advisement ("I am not a doctor" is pretty clear). Obviously the answer among the people who *are* self-identified as doctors in this thread varied greatly. To the extent this is a medical question, there is no clear medical answer (perhaps in large part because the question was presented without a lot of background information and relates more to palliative care than the care doctors directly provide).

It's often stated by various members in this forum that too many people try to label issues as psychiatric when they are not, especially as it relates to "bad behavior" and that the field of psychiatry becomes too ensnared in fixing society's ills when its original focus was meant to be more narrow.

I would argue that toward the end of a person's life, or really at any stage, but particularly at the end, issues like this will arise that are part of the human experience. And I am less inclined to see it as medical. I don't think you can medicalize every decision a person makes.

I would not assume the identity of anybody in an anonymous public forum, and I would hope that my medical care was not based on a doctor assuming that. If it gave someone an idea that they vetted with someone in real life or that was consistent with their own medical knowledge, that seems like a fine use. But I don't think anyone is realistically making treatment changes based solely on any individual post here, and if they are and something happened, it's still their responsibility. I don't assume or believe the OP is a doctor. And I don't think this was a peer to peer request; that's just my instinct.

 

[Crayola227]

As I previously stated, my status said that until it was changed (out of my control—I can longer edit it, but someone wrote for me "non-medical"—it was previously more specific), and as you said yourself, I did state in this thread that I am not a doctor, as well. I can attempt to expound on that more in the future if this situation comes up again, but I rarely offer advice, and to the extent you think advice about holding a trip to Atlantic City as a bargaining chip over someone close to the OP based on whether they take a shower or not is a medical question when they are in denial about their health status, I think I offered enough advisement ("I am not a doctor" is pretty clear). Obviously the answer among the people who *are* self-identified as doctors in this thread varied greatly. To the extent this is a medical question, there is no clear medical answer (perhaps in large part because the question was presented without a lot of background information and relates more to palliative care than the care doctors directly provide).

It's often stated by various members in this forum that too many people try to label issues as psychiatric when they are not, especially as it relates to "bad behavior" and that the field of psychiatry becomes too ensnared in fixing society's ills when its original focus was meant to be more narrow.

I would argue that toward the end of a person's life, or really at any stage, but particularly at the end, issues like this will arise that are part of the human experience. And I am less inclined to see it as medical. I don't think you can medicalize every decision a person makes.

I would not assume the identity of anybody in an anonymous public forum, and I would hope that my medical care was not based on a doctor assuming that. If it gave someone an idea that they vetted with someone in real life or that was consistent with their own medical knowledge, that seems like a fine use. But I don't think anyone is realistically making treatment changes based solely on any individual post here, and if they are and something happened, it's still their responsibility. I don't assume or believe the OP is a doctor. And I don't think this was a peer to peer request; that's just my instinct.

For the me issue wasn't when you opined about end of life and showers, as certainly there can be a lay view on the topic of hygiene or priorities of energy expenditure. It was more when you were trying to elicit more detailed background medical information and especially when you started talking about medications and health conditions that I felt you did actually venture over into health advice. Honestly, it was enough that I had to doublecheck who was posting and that it was indeed you. If I wasn't familiar with you already I could easily see someone not catching you are not medical and thinking that maybe you were.

While I wouldn't expect a physician to have care meaningfully swayed by attention to an online forum without looking into the matter further (vetting the source or double checking the info with a better source), I don't know that I feel as confident saying that would be true for basically anyone else reading.

I don't say this to beat up on you, because I generally appreciate the additional perspective you bring to the forum, but because I was honestly a bit taken back by some of the posting. I think Mass Effect's criticism here has some merit and that's about it.

When I responded by the way, I purposefully didn't try to elicit more detailed medical history. Because I think it was important to demonstrate what the appropriate medical thought process is when faced with a question like this with so many unknowns. It's important to explain like, "here's what we don't know and why we can't advise in this situation this particular answer this person is looking for." The reason is because as providers we are frequently faced with this kind of thing. It's one thing for us to formalize an answer when we know particulars, and another thing when faced with the ambiguous.

And note that nothing we learned contradicted any of the points I made. That was intentional. We were asked for a stock answer and I gave one. Having more information didn't really change the assessment and just really ended up reinforcing the one I gave.

OTOH, digging in more led to a lot of stuff that got very specific about medications. This is frankly less ideal, because that is a little bit beside the point, and without a full chart review and patient exam getting more specific might be problematic. I am of the opinion this was best approached as a vague question and the right answer about hygeine for this unseen person is, "it greatly depends."

To be frank, you didn't seem to get that it was inappropriate to dig and try to be more specific in this case. No amount of chart info in this case can really let us advise specifically
- we haven't seen her skin, her bed sore, or assessed her mental status and level of physical strength, all of which are important for gauging her hygeine and ability to safely shower or bathe. I know others gave some very specific opinions about medications, but they also weren't the ones initially eliciting more specific info. I think it wasn't totally appropriate here to get into for this unseen patient.

I normally wouldn't have made a point of saying where I thought you went wrong, but since it's led to this conflict I thought I would add my two cents.

In any case it's a very important skill for a provider to explain to a lay person why they can't give a specific opinion in many cases. Many times formulating that answer is less straightforward than forming a complete medical opinion.

 

[Mass Effect]

It's often stated by various members in this forum that too many people try to label issues as psychiatric when they are not, especially as it relates to "bad behavior" and that the field of psychiatry becomes too ensnared in fixing society's ills when its original focus was meant to be more narrow.

I would argue that toward the end of a person's life, or really at any stage, but particularly at the end, issues like this will arise that are part of the human experience. And I am less inclined to see it as medical. I don't think you can medicalize every decision a person makes.

See @Crayola227's post above for response to this. You are correct that not every decision is pathologic, but knowing what is and isn't is, perhaps, beyond your expertise. Look, I'm not telling you not to post or not to say what you think. I'm saying, as I've said before, to people new to the forum or people who are from other specialties who don't spend much time here, it should be made clear who is responding. If SDN took away your non-medical designation, that just means that you should state it. "I'm not a doctor" isn't the same as saying you're not a healthcare provider. Anyway I'm done with this discussion. I said what I had to say and I've said it before to you because I find some of your responses to be bordering on the inappropriate without that disclaimer.

 

[birchswing]

For the me issue wasn't when you opined about end of life and showers, as certainly there can be a lay view on the topic of hygiene or priorities of energy expenditure. It was more when you were trying to elicit more detailed background medical information and especially when you started talking about medications and health conditions that I felt you did actually venture over into health advice. Honestly, it was enough that I had to doublecheck who was posting and that it was indeed you. If I wasn't familiar with you already I could easily see someone not catching you are not medical and thinking that maybe you were.

While I wouldn't expect a physician to have care meaningfully swayed by attention to an online forum without looking into the matter further (vetting the source or double checking the info with a better source), I don't know that I feel as confident saying that would be true for basically anyone else reading.

I don't say this to beat up on you, because I generally appreciate the additional perspective you bring to the forum, but because I was honestly a bit taken back by some of the posting. I think Mass Effect's criticism here has some merit and that's about it.

When I responded by the way, I purposefully didn't try to elicit more detailed medical history. Because I think it was important to demonstrate what the appropriate medical thought process is when faced with a question like this with so many unknowns. It's important to explain like, "here's what we don't know and why we can't advise in this situation this particular answer this person is looking for." The reason is because as providers we are frequently faced with this kind of thing. It's one thing for us to formalize an answer when we know particulars, and another thing when faced with the ambiguous.

And note that nothing we learned contradicted any of the points I made. That was intentional. We were asked for a stock answer and I gave one. Having more information didn't really change the assessment and just really ended up reinforcing the one I gave.

OTOH, digging in more led to a lot of stuff that got very specific about medications. This is frankly less ideal, because that is a little bit beside the point, and without a full chart review and patient exam getting more specific might be problematic. I am of the opinion this was best approached as a vague question and the right answer about hygeine for this unseen person is, "it greatly depends."

To be frank, you didn't seem to get that it was inappropriate to dig and try to be more specific in this case. No amount of chart info in this case can really let us advise specifically
- we haven't seen her skin, her bed sore, or assessed her mental status and level of physical strength, all of which are important for gauging her hygeine and ability to safely shower or bathe. I know others gave some very specific opinions about medications, but they also weren't the ones initially eliciting more specific info. I think it wasn't totally appropriate here to get into for this unseen patient.

I normally wouldn't have made a point of saying where I thought you went wrong, but since it's led to this conflict I thought I would add my two cents.

In any case it's a very important skill for a provider to explain to a lay person why they can't give a specific opinion in many cases. Many times formulating that answer is less straightforward than forming a complete medical opinion.

That's extremely thoughtful. Thank you. In my mind when I was asking those questions, I was more sort of pushing the idea not in particular about what she was on but that there was probably a more serious issue (frankly just along with the age) than the shower itself. There was a lot of information offered before I inquired as to the medications, as well.

"What do the 11 meds do? That's a lot."

I know old people often take a lot of medications. I was less curious about what they do than pushing toward the idea that something bigger is going on—acceptance of old age—that I thought was being missed.

I later wrote:

"I'm not a doctor. That's a lot of meds, and it sounds like she is having a lot of the health issues an 89 year old would have, and I'd say yes let it be regarding showering."

My later point in pushing about the heart disease and cognition meds was not to try to figure out the nuts and bolts of it all but to reflect back the human story that the OP didn't seem to recognize entirely that this is an elderly person with several diseases, and then there is the talk about the shower, which in the end may not be what is important.

I felt like I had a rhetorical purpose in asking the questions and pushing back on what seemed like inconsistencies, but I can see how that in and of itself could be too close to trying to be therapeutic.

 

[FlowRate]

I'm still curious how this thread fit in the psychiatry forum, although I guess we are the general dumping ground for anything social. Which is also one of the few distinct downsides of my current employment... I miss having a dedicated geri service.

 

[Candidate2017]

Acting like the way to treat or modify elderly behavior by infantilizing them or treating them like animals is also a pretty disgusting and inappropriate approach.

I don't think they were being insulting. Most of the field of psychology and many psychotherapeutic principles are based on animal (non-human and human) experiments and child development. In any event, we are just animals, specifically large infants.

 

[Crayola227]

I don't think they were being insulting. Most of the field of psychology and many psychotherapeutic principles are based on animal (non-human and human) experiments and child development. In any event, we are just animals, specifically large infants.

This is another and a possibly better way to put it. Once you clarify that this is how you are approaching ALL people, not just the elderly, it takes on a different bent. Some people hold an unconscious bias towards infantilizing the elderly specifically and I think that is where we need to try to show some sensitivity.

 

[futuredo32]

My Grandma had dementia and near the end showers TERRIFIED her. She took a great sponge bath twice a day and washed her hair in the sink every other day. You have to pick your battles. I tried to give her the highest quality of life possible. Every few months I made her shower, but she didn't smell, had no skin break down. I tried EVERYTHING to make it less scary for her. They were 5 minute showers with her sitting on the bath stool and they were horrible for her. If the patient isn't harming themselves , leave them alone.

 

[AcronymAllergy]

I don't think they were being insulting. Most of the field of psychology and many psychotherapeutic principles are based on animal (non-human and human) experiments and child development. In any event, we are just animals, specifically large infants.

This. Behaviorism is powerful, it just so happens to work with animals and infants (or rather, it worked on animals and infants, because psychologists apparently love to experiment on their on and others' kids, and then just so happened to also work on all other sorts of humans).

And behavioral principles can specifically provide models of more effective intervention than heavily cognitive- and insight-based therapies for situations when cognitive skills are significantly impaired, such as with advancing dementia and some neurodevelopmental disorders (e.g., severe to profound intellectual disability). But that certainly doesn't mean behavioral principles are only used in those situations.

Although I agree that the elderly, and particularly elderly individuals with cognitive impairments, are far too often minimalized and infantilized. I've seen too many instances of clinicians immediately turning to talk about a patient to their family member as if the patient weren't there at the earliest sign of any difficulty understanding or responding to questions. I'd be pretty pissed if that happened to me, too.

Going back to the OP, plenty of good suggestions have been provided. It's a matter of weighing actual health risks with quality of life and patient preference.