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NO IDEA WHY THE PATIENT IS THERE
Becky, the nurse, had worked with psychiatric patients for years. She knew what to expect from them. Today, though, she was completely flummoxed. She couldn't tell why the next patient, a pleasant 81 year old female, was there. Apparently the patient didn't know either. Mrs. K was very nice about it, she trusted her doctor and her doctor said she should be here, so Mrs. K had made and kept the appointment to see me.
I asked Becky what, if anything, she had found out about the patient. She just shook her head. Mrs. K. was a little balmy, mentioned some concerns about entertaining family members and feeling stressed by having to make a big meal for them several times a week, but that was all. There really wasn’t anything that stood out as being particularly abnormal.
It was my turn to see if I could figure out what the issue was.
Mrs. K was charming. She smiled and asked how I was. She complimented me on my hair and what I was wearing. But when asked if there was anything she might have said to Dr. Smith to make him think she needed my help, she just shook her head.
PATIENT'S HUSBAND IMPATIENT
Mrs. K 's husband sat nearby. He had a Vietnam veteran's cap on his head, an olive drab army vest over a blue plaid shirt. He leaned slightly forward, right hand on top of left on top of a cane. Mr. K let out a loud "Humph," then glared at his wife.
She smiled, focused her attention on me and ignored her husband. She shook her head. “Well, I’m not sure this is why anybody would send me to see a doctor, but I do have trouble making sure the people who come to our house are fed properly.”
A number of possibilities as to why she might need to see me were running through my head as we talked. Obsessive compulsive? Social anxiety? Guilt feelings that she should be doing more for others?
GUESTS ARRIVE UNANNOUNCED
"They usually come for supper. I'll spend all day cooking but when they get there, lots of times they don’t eat anything. They’re just gone.”
My ears pricked up. She didn’t say they left. She said they were gone. “Who are these people? Are they people you know? Are they always the same people?"
Her husband let out a “harrumph” on his side of the room but said nothing.
“Oh yes, they’re my sister-in-law and my brother and a cousin or two. They just drop in. It's
kind of surprising, since they live in Chicago. I hadn’t seen them for quite a while. I have to admit I don’t really care much for them, never thought they treated me nice. But I would never refuse to feed them if they’re guests under my roof.”She started to look distressed.“They still don’t treat me nice. I set a lovely table with my best china and silverware and they just look at everything and go without eating a bite. And I spend all that time over a hot stove and come up with such nice meals for them.”She shook her head again, a look of extreme hurt on her face.
Okay, the story was coming apart. It was unlikely that a brother or sister-in-law who undoubtedly weren’t young either, would be making the trek to see her unannounced from Chicago, which was several hours away. We were starting to make some progress.
“Do they appear at any particular time of day or night? Time of the week? Time of the month?” Was she “sundowning” I wondered? Hallucinations?
“Oh my no. They just come right on in the house and I never know when they’ll show up. And I’m always afraid they won’t be fed properly. I ask them if they want something and they always just look at me.”
Her husband again made a growling type of noise, but this time he couldn’t contain himself. “You’re not telling the best part” he chided her. She looked at him questioningly.
“You know…” he said, apparently trying to get her to say what he was thinking.
NOT TELLING THE BEST PART
“You forgot to tell her they’ve all been dead for ten years.”
She blinked at him, then turned to me. “Oh yes, I didn’t tell you that part. They’re dead. And I wish they wouldn’t come and look at me that way. But since they’re here and they’re my guests, I don’t want them to go hungry.”
Again he rolled his eyes. It was clear she had no recognition of the fact that what she was saying was rather difficult to believe.
“So you know that all of them have been dead more than a decade?”
“Oh my yes. I couldn’t get to his funeral. Gus was in the hospital and I just couldn’t get away. But she died just a few months later and I was able to go down to the funeral for that one.” She suddenly looked thoughtful. “I wonder if that’s why they’re here… you know, they don’t feel like they were adequately cared for at their funerals? I know I wasn’t able to bring a covered dish.”
Her husband clearly couldn’t stand it anymore. “They’re dead,” he shouted. “There’s nobody there. I’ve told you that a thousand times. They can’t be here because they’re all dead and buried.”
She nodded and tried to console him. “Yes, yes you have dear. Especially when she started wearing your clothes and sitting in your chair. Sometimes I look and I think you’re there, and then I realize she’s doing it again…borrowing your things.”
He looked at me, pleadingly. “How do I get her to understand that there isn’t anybody there? She won’t let me sit in my recliner if she thinks there’s somebody already there in my bathrobe.”
“You probably can’t,” I say. “There’s no point in arguing about it. It will upset you both and she isn’t going to believe it anyway.”
He nods. “I’ve sure seen that’s the case. But it just bothers me so much that I can’t get it through her head. "
UNLIKELY PILLS WILL STOP THE PROBLEM
I shook my head sympathetically. I gave them a prescription, instructions on how to take the pills and what to look for in terms of side effects. We really didn't have much of anything that would counter Mrs. K's visual hallucinations, but I knew this would work quickly if it worked at all. I wandered out to find samples to give the octogenarian.
When I returned, a bag full of medication for them, I asked if they had any questions. He shook his head and started to rise, leaning heavily on his cane. She, on the other hand, looked concerned. “I guess there is one thing I’m worried about.”
I stopped at the door, knob in hand. “Yes? What’s that?”
“How can I get them to just sit down and have supper like they’re supposed to? When I’m the hostess, that’s my job.”
Her husband rolled his eyes and headed down the hallway, leaning heavily on his cane.
Military insignia image by: zm23
Meal image by: bhofack2