When Medicine is Not a Pill

Robert Burns

 Carolyne slumped back in her wheelchair.

“I’m shitty,” she said.

Carolyne is 85 years old, and has lived in a memory care facility for almost a year. Over half of her time in the fifteen-person unit has been spent in quarantine; family visits have been stopped by state order five months ago.

I’m a geriatrician, and the only outside person to have visited her during the isolation. Her days are limited to contacts with the nurses and aides, supplemented by face time contacts with her daughter.

The note from the nurse that morning told me Carolyne had lost weight; she was down nearly thirty pounds over four months.

I asked her about her appetite and food preferences. Like many older adults in assisted living, she dismissed it with a wave of her hand. The kitchen had been making her personal meals, trying to prepare her foods that she will eat. It was not been successful. I told her that she had lost weight.

“I’ll fit in the casket better,” she said. She smiled.

I explored her comments, probing for depression, thoughts of self-harm. She has dementia and several other chronic illnesses. I concluded she is exhausted from her isolation.

In Tennessee, where I live, and all across the country, older adults are locked in nursing homes and assisted living facilities. The precautions are prudent. To date there have been over 170,000 COVID-19 deaths in the United States. According to the CDC, 8 in 10 of US deaths have been in people 65 years and older.  I’ve worked in nursing homes during the pandemic. In a couple of them the virus spread like fire in a dry forest, killing dozens, and infecting staff and other residents. Walking through a nursing home with a COVID outbreak was a surreal experience; masks and gowns and distancing from the staff and patients made physical contact, human touch, with those who needed it most impossible. Being in an infected nursing home during the initial dark days of the pandemic, while we were all gathering our footing, was an apocalyptic hell I would not wish on anyone.

Several months ago, I had a visit with Marjorie, a 75-year-old woman in one of those infected facilities. She had dementia and strokes, and had become infected with the virus. She had stopped eating. She was more confused, and interacted less. It was clear she needed to be on hospice care. I called her sister to discuss her situation. Because of the lockdown they had not seen each other for almost two months. For ten minutes I held my phone so the two of them could Face Time, the first time the two of them had seen each other since the quarantine. Marjorie talked to her sister over the small screen. They both said “I love you.” Marjorie was more interactive with her sister than she had been with me, and I told her sister.

“Family is medicine,” her sister said as she wiped tears off her cheek.

Carolyne needs her family. I agree isolation was the right decision when the pandemic was exploding in spring and early summer. I’ve worn masks since April and have been tested for COVID nine times to make sure I don’t infect my patient. But in my experience, all isolated older adults, especially in facilities, need family contact.

Reuniting with family members in assisted living and nursing homes is at the intersection of facts, science, and policy. I write this in a state that has not mandated masks and struggles with getting the virus under control. But I believe there is a way to move forward, at least for now. I am confident that if family members were isolated before visits, wore masks and socially distanced during their visit, families could have brief encounters together. The risk of spread with a brief hug or touch is minimal, with the above precautions.

There is no medicine which will make Carolyne eat or improve her mood. She needs to see her daughter.

Note: Patient names have been changed.