Frank Mills is a 94-year-old widower who has been in your practice for many years. He is a retired army colonel, businessman, and college teacher with many awards and mementos on his walls in his continuing care retirement home. He requires daily support from the aides and nursing staff. He has cerebrovascular disease (CVD), hyperlipidemia, prostate cancer, glaucoma, and recurring deep venous thrombophlebitis (DVT). His diffuse degenerative lumbar arthritis with spinal stenosis has progressed and contributed to chronic back ache, leg weakness, gait instability with several recent falls, and bladder atony requiring an indwelling bladder catheter. His CVD is diffuse, with a history of transient ischemic attacks, scattered small deep lacunar infarcts, and white matter disease on magnetic resonance imaging. The CVD contributes to his gait slowness and instability. He receives bicalutamide (Casodex) and leuprolide (Lupron) treatments from an oncologist, and his prostate-specific antigen (PSA) has been low. He has not had a recurrence of his DVT or new transient ischemic attacks in the last couple years while on warfarin. His international normalized ratio is kept at around 2.0 and he has not suffered significant bleeds. For years his hyperlipidemia has been controlled with atorvastatin. His sight is declining significantly in spite of frequent ophthalmology consultations and adjustments of his glaucoma management. His mild chronic memory deficit has been more evident in recent months.
The nursing director notifies you that Mr. Mills is not eating as well as usual, and has lost about 5 lbs in 60 days. The fitness center director reports that he is not the usual enthusiastic exercise participant he had previously been.
1. Would you consider Mr. Mills to be frail, and if so, why?
2. List significant possible contributors to Mr. Mills’s functional and physiologic decline.
3. List key components of your multilevel plan of action to address this decline.
Mr. Mills requires careful broad-focused attention to his growing weakness, weight loss, and functional decline. His bladder catheter places him at risk for an occult bladder infection, which must be investigated. The status of his prostate cancer must be reviewed. Untoward effects of his medications on his appetite and well-being should be considered. The effectiveness of pain management, particularly the low back pain, must be reviewed. His ability to feed himself and swallow safely should be explored. His mood, never before a problem in his active life full of high achievements, should be assessed. With his declining gait and mental status, the possibility that a fall has led to an occult subdural bleed, particularly with his warfarin treatment, should be entertained. These issues are all addressed over the course of the following month, as is a thorough review of possible emerging new issues, but no new problems are unearthed. However, a mental status exam shows a significant decline from the previous year’s score, consistent with his growing need for the supportive services.
1. You are to meet with Mr. Mills and his daughter to summarize the findings of your investigation. What will be the major themes you will address?
2. What suggested care plan changes will you bring up?
3. What other team members do you need to collaborate with for the best outcomes for Mr. Mills?