Reply To: Live Workshop 2

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Lilia Graue, MDLilia Graue, MD

Alicia and Howard, and everyone else who’d like to chime in, I have a question and a case related to the question.

Have you worked with elderly patients with cognitive decline? If so, are there specific suggestions you’d offer for working with this population?

I’ve been working with an 82 yo F with Parkinson’s, depression, cognitive decline, vasculitis, hypertension and hyponatremia, who was referred to me for post-herpetic neuralgia, and it’s been really challenging.

The greatest success so far has been with her children, who were very open to psychoeducation about primary pain and to working through the fear/avoidance cycle. They have stopped organizing around the pain, and have made significant shifts in how they relate to her, in addition to organizing more family gatherings and more frequent visits with her children and grandchildren, which brings her joy. They are making the best of her good days and keeping her company on not-so-good days, and she recently went on a short trip to the beach with one of her daughters and her family.

She and I have established a good rapport, and during the time we’ve been working together she has grown in willingness to engage socially, with ups and downs. Her children have shared that she seems more engaged and in general her mood has had a positive trend.

In terms of the pain, we haven’t had much success with the neural repatterning toolkit – psychoeducation has been incredibly difficult; she will sometimes agree to have me guide her through somatic tracking, mindfulness and compassion practices, and sometimes she won’t; she refuses to practice in-between sessions; any and every time we come near difficult events/emotions she gets intense pain but denies any connection between her emotions and pain (other than that the pain seems to come at random times, and is not triggered by movement); she refuses to engage in physical movement beyond two days a week during her PT sessions (her mobility is quite limited – her muscle mass is very very low, she can walk with the help of a walker with the tiniest steps, and for most of the day she sits on a recliner), and won’t leave her room unless her children are visiting (and even then it’s a struggle unless it’s a large family gathering downstairs). She’s had several episodes of severe hyponatremia and UTIs during the time we’ve been working together, with associated lethargy. She has a history of poor health in childhood, lost her father to suicide in her teens, and her husband has had an extramarital relationship for decades – they keep separate lives though they live in the same house and will both be present for family gatherings and celebrations. During the pandemic several of her friends and elderly relatives died, and the remaining ones are not meeting anymore like they used to. She has live-in nurses and both they and her children have tried everything to encourage her to be more active and/or do guided practices, but she gets combative. There have been episodes during which she refuses to bathe or to get up to urinate for a few days, which usually ends with a UTI.

My role in her medical team is in the psychosocial domain. She has a neurologist, a geriatrician, and a rheumatologist seeing to the medical aspects, and her daughter is also a physician.

Any insights or suggestions would be much appreciated, thank you!