Mr. Michalowicz lives alone in his own apartment in New York City, but is confronting increasing health problems. Not long ago, he was hospitalized, spent time in rehab and was suffering from delirium, which was successfully treated. But he never fully recovered from these events. He has fallen many times at home and while hospitalized.
- Costs of Care
- Medicare/Medicaid pay for hospital costs and doctor fees.
His Doctor's Comments
Here, Jeffrey Farber, a geriatrician and a member of Mt. Sinai Hospital's Visiting Doctors Program, talks about Mr. Michalowicz, why he feels a special connection to this particular patient, and the problems that likely lay ahead for him.
Mr. Michalowicz is -- you love all your patients, but you do have your favorites; you have people that you feel a closer bond with, and he's one of them. He's a Holocaust survivor, and he lives alone in the city. His wife died a number of years ago, and that really devastated him, and he's been lonely and depressed and isolated ever since.
He has lots of issues as well, related to being a survivor: the trauma that he suffered and experienced, and the torture. In addition, he's got some pretty serious health problems. He has very advanced lung disease and very difficult-to-control diabetes and very bad arthritis that makes it difficult for him to even take his pills out of his pillbox. We spend a lot of time trying to figure out how he can take his medicines, of which he has many to take, when he can't open the pill bottles and can't put his fingers into them to get out the medicines.
“[He] is a type of person who is not uncommon -- lonely, depressed, very isolated, and has a kind of passive, suicidal ideation. If you ask him, he wouldn't mind if his time came and he died tomorrow.”
Jeffrey Farber, MD
He also recently has been developing incontinence, which took him a while to tell me about, even though I feel that we have this close relationship. He's a very proud person and didn't want to talk about something so personal and, in a sense, a marker of frailty and loss of independence. It's a challenge for him. For example, he had trouble going over to his neighbor, who's been very helpful and very involved, for a Thanksgiving meal because he was just too embarrassed about not being able to control his urine despite attempts to try and treat [it] and use adult diapers. It's tough.
[Tell me about his depression.]
It's very difficult to treat his depression. He doesn't want to go out to adult day centers -- even ones very close by -- and meet people. He loves socialization. He loves coming to the office and seeing us. He loves talking to us and spending time here. He has a very close relationship with his neighbor. And there are caregivers that have been sent from other nonprofit organizations to help out. But he won't really leave the home.
One of the biggest headways we made recently was getting him to agree to have someone in his home to help him for several hours a day, most days of the week. She's been a really great help. They've formed a good relationship, and he trusts her, and I trust her, and it helps. It really helps. I've seen it make a difference for him.
Is that loneliness and isolation a huge factor?
Mr. Michalowicz is one of a type of person who is not uncommon; who is lonely, who is depressed, who is very isolated, and has a kind of passive suicidal ideation, we call it. If you ask him, he wouldn't mind if his time came and he died tomorrow. He kind of feels that he's outlived himself and doesn't feel that there's all that much left for him to live for. But at the same time, he's not going to go do something about that, and he's clear he's not wanting to actively kill himself. I think for him, that depression and that isolation is more of a problem than any of his other medical problems. Even his breathing problem, which is very severe, I think it pales in comparison to how he's struggling ... with his depression.
How does it make you feel? I watched your care as he left. Is that part of what you do?
Part of it in geriatrics, too, is a closeness. It's a willingness to be with people, to touch older people. They feel it. They know that other people are kind of repulsed and don't want to come near. As a geriatrician I'm not, and personally I'm just not. To have a kind of rapport is important, and to feel comfortable with the person, to put your hand on his shoulder, is very reassuring, and it means a lot.
At the same time, it's tough. I see people making bad decisions all the time, and you wish they didn't. But people do it all the time, and you just have to live with that as a physician. ... For example, with Mr. Michalowicz, I can't make him go to the day center across the street. I try; I recommend; I ask other people to convince him. But he won't, and he won't, and he won't. And it's sad, and I wish he would. I won't stop trying to convince him unless he tells me, "Stop, I don't want to talk about it anymore," which he doesn't because he likes to talk about it, but it's tough. It's tough.
What's ahead for him?
Well, he recently recovered from a pretty long, complicated episode with a few hospitalizations and a long stay and some rehab. It was a tough time, and I wasn't sure he was going to pull through. [For] a lot of older people, any visit to the ER could be the beginning of something devastating. You never quite know what's going to happen. But he pulled through and has now been relatively stable for quite some time.
In the clinic, he cried about his wife. Did his entire family die in the Holocaust?
Mr. Michalowicz opened up to me once in particular a while ago about the Holocaust and told me a lot about his personal experience. His family did all die, were killed in the Holocaust. He was in a concentration camp and was liberated by the Americans when they came at the end of the war. He actually married a non-Jewish woman from Poland, which is where he's from, after the war. They moved together to Israel for some time and then eventually to the States, where he's been here now for 30 years or more.
She died about five or six years ago. He was so close with her, it was devastating. He was really dependent upon her for all of his needs and for his just being who he is and didn't have that kind of relationship or bonds with other people, with other family or friends, and has been resistant to develop that with someone else after she left. So he's still traumatized by her death and very much alone. ...
I worry a lot about him in particular. ... He certainly is at risk, and that's why every time I see him I ask him specifically, "Do you plan on killing yourself?," or "Have you thought about killing yourself?" ... If you don't ask, you don't know, and people tend to tell you the truth.
He also seemed upset about [losing] his memory.
His memory problems have been a challenge. He has had good normal memory for a while, and then when he had this episode, and he had a lot of bleeding, and he had an exacerbation of his lung disease, and he was in the hospital for a while, he developed delirium, which is not uncommon for older adults, especially with multiple medical problems, and the delirium affected his thinking. It lasted a long time, and it actually took us a while to figure out what it was. In the end, it was related to a pretty rare lung infection that we were able to diagnose during one of the hospital stays. [It] cleared up and got better with treatment, but he never quite got back to his baseline. Those periods of confusion -- he's aware of them, and he knows what he doesn't know, and it's frightening.
It's also tough from my standpoint, because I can't fix it. As much as I want to make that go away, I really can't. I've tried just all sorts of things to figure this out, and the only thing we came up with was what we're treating. He got better, but never quite the same.
It's not uncommon for people with dementia to first present like that. Something happens, and it's delirium, and then later on, as that clears up, you realize that that was the beginning of a dementing process, which he may have. ...