Geriatrics at the VA

I started my Geriatrics rotation at the Cleveland VA yesterday. This is the first time I have ever been inside the VA hospital, and it is surprisingly nice. The floors are all wooden, and there is a lot of cool, funky furniture and artwork in there. A lot of the rooms are single. The patients wear what I can only describe as pajamas with the VA logo on them. The funny part is that the logo says, "property of the government" right there on the patients' chests. There are five students on the rotation: me and four fourth years from the UP. The faculty always ask us what we want to go into here just like they did at CCF. I'm the only one who still doesn't know, because these fourth years I'm rotating with are all going on residency interviews already. So I always have to explain that I'm only a third year!

For this whole week, I will be spending my mornings on the GEM, which is the geriatrics inpatient floor. I've only been seeing one patient per day, mainly because these patients are incredibly complex. I was joking to a friend that they couldn't be much different than a lot of the patients I saw on General Inpatient Medicine at CCF. But actually, they are a lot more challenging because most of these patients have dementia, delirium, or both. The main difference between dementia and delirium is that dementia is a permanent state of altered cognition, while delirium is usually a temporary, fluctuating state. The reason why it matters is that delirium is sometimes curable if you treat the underlying cause, but dementia (like Alzheimer's disease) usually isn't curable.

So the schedule basically goes that I come in each morning around 7:30 AM and see my inpatient. He has moderate dementia and is also recovering from a post-surgery episode of delirium. What fascinates me the most about working with him is that he is actually capable of performing several activities of daily living like feeding or dressing himself, but he has to be coached. For example, he can use a knife and fork to cut his pancakes and eat them, but only if I tell him what to do, step by step. Otherwise, he picks the pancakes up with his fingers. I can understand why these patients are difficult to manage at home. He is just as docile as a young child, but also just as dependent. It would be impossible for someone to stay there and constantly coach him all day long.

We have team rounds at 8 AM on Mondays, Wednesdays, and Fridays, and a lecture at 8 AM on Tuesday and Thursdays. (We start rounds at 9:15 AM on Tuesdays and Thursdays.) I was a little worried about the rounds, but they've been surprisingly short and painless. This is mainly because we only have half a dozen patients on the team, as opposed to the two dozen we would have on Medicine at CCF. Today's lecture was on delirium. After rounds, we finish seeing our patients and writing notes if we haven't already. I've been getting in early enough to get everything done before rounds, so it gives me the rest of the morning off to get other things done.

In the afternoons, I go down to the outpatient clinic. Again, these are mainly patients with dementia. Conducting the interviews can be a huge challenge, because a lot of the patients aren't able to focus on the discussion very well. As you can imagine, it's pretty hard to perform a mini-mental exam on someone who constantly goes off on illogical tangents or confabulates (makes up stories to fill the gaps in his memory). The other thing about the mini-mental is that it's specific but not very sensitive. This means that there aren't very many false positives (i.e., most normal people will not come out with a score that suggests impairment), but there are a lot of false negatives (people who are demented but score high enough to suggest that they aren't). The reason why there are so many false negatives is that someone who is highly educated (beyond high school) can often compensate for their cognitive deficiencies. So basically, if you have a college education or beyond, you would probably be able to "beat" the mini-mental even if you were mildly or moderately demented.