Patients Old and Young

The patient wears her straight white hair short like a flapper from the thirties. While she moves randomly in her chair, her face is mobile and her dynamic presence engages all in the room.
"I don't like to think of myself as having Parkinson's Disease"- she tells the medical student. She uses no term to describe her dyskinesias- she simply says, "When I am like this"- gesturing towards her body. The doctor is unsure whether the movements are due to levodopa levels peaking or subsiding. He encourages the woman to keep a medication journal for several days and to bring it when she visits again. With a week's worth of hourly details listing medications and her physical symptoms, he will be better educated to tweak her drugs and reduce the unwanted movements.
In a restaurant no one wants to sit next to her; the movements are embarrassing. She describes her children's response to her initial session with a physician; they thought she was cured. Levodopa quieted everything.
Now balance and freezing become problematic. She takes no antidepressants. She sleeps well, with one Vesicare she wakes only once to use the toilet. The doctor recommends physical therapy, as freezing can be a source of falling incidents. Sun City- a retirement community south of Tampa is her home for the winter half of the year, by April 30th she returns to New York.
"Try and get an appointment in April, I'd like to see you before you leave."
The medical student has long golden hair, hanging loose and straight down her back. Beneath her white lab coat, she is curvy but tall. She reports on another regular patient providing key issues of his visit. The second student, still an undergraduate, is dark, slender and intense. Thick black thick hair comes low on his forehead. When he is not commenting, he takes notes. His assertive voice and commanding attitude give him an authoritative air.
Diagnosed in his late thirties, the patient has had PD for ten years. He notes he feels weak in the legs sometimes, as if lacking the muscle strength to hold his body erect. Dramatizing this he hops from the examination table, performing several steps with bent knees. The doctor nods but has no comment.
The wife notes when very happy or sad, the medications seem to have no affect. Neither the doctor nor students provide any explanation. The physician takes the patient's arm, testing for cogging in the wrist or elbow and comments on the patient's muscle tone, noting he must be active. The client concedes he cuts the lawn, but maintains his bicep with fishing.
The edges of the man's mouth droop slightly at the corners, making him appear sad. Describing his experience with Amantadine, he saw the ceiling slant downward at an angle and the floor slant upward. He felt space would compress him. His hands felt enormous and his body barely fit through the doorway.
Addressing the cost of medications, Mirapex in particular, the doctor suggests switching to Bromocriptine. Used during the seventies, it is an alternative generic option. Expressing doubt about whether it will be as effective as Mirapex, the doctor leaves the room, returning with a white bag of sample bottles.
It is four o'clock. The patient swallows a pill as the doctor explains to his wife, which cold medications may combine safely with the drugs he is taking. Soon after, the patient freezes in the hallway. He turns his wide shoulders sideways performing a maneuver he hopes will unlock his frozen feet.

Hushed

The patient's voice is so soft it's hard to believe he's not pulling some sort of joke. The voice or the lack of one doesn't change the doctor's regular speech pattern. He wants to know what medications the patient takes. The patient responds slowly and softly, indicating he doesn't know the dose of the pill he takes. The doctor gazes down at the chart at the list of medications and asks the patient how the drugs got in the chart.
"I remembered them." The doctor shakes his head in agreement but he's not convinced the patient is lacking more than a voice. He asks the medical student to get a mini- mental form, then asks the patient whether he knows where he is and what the date is. Satisfied somewhat the doctor questions the man about why he takes two pills per day. The pale man responds he had the sensation he was wearing long gloves on his forearms so he stopped increasing the dosage.
With two pills per day, the doctor can't say whether a patient would experience any relief from symptoms. He's irritated. It's been six months since the patient's last visit and he still can't determine whether the man is benefiting from the drugs. The doctor writes out a drug schedule, increasing half a pill every three days until the man takes up to two tablets three times per day. It's an outline, or a staircase the patient can go up and down on. The physician clarifies he wants the patient on a larger dose to determine whether levodopa is helping the symptoms or not. Signs of illness appear a little worse.
The man's noticed a slight drool from the side of his mouth, his facial expression seldom changes and his blood pressure is quite low. So low, the clinician worries an increased dose of levodopa will send it plummeting; he writes a prescription for florinef, which will keep blood volume high so the slight man won't faint when he stands up. Another worrisome symptom is anemia; patients with Shy- Drager Syndrome frequently are anemic. A stool softener, I notice in the chart, another sign of autonomic nervous system involvement.
We watch the slender man walk down the hallway. Is it the cell phone hooked to the belt that makes his left arm jut out? He breaks the turn in fractions rather than gliding through it. The forward head and rounded back catch in the doctor's teeth. He will recommend physical and speech therapy and will see him again in six months.

Sixty- five but Much Older

The dilemma of the clinical visit was to arrive at a possible diagnosis for the patient. He demurred to his wife's opinion often, maybe he became this way over the last year as he experienced declining intellectual function. Maybe he had always been the milder, softer one. He never noticed the shuffling gait. His wife commented on it while they vacationed in Italy and walked over the cobblestone streets.

He noticed not being able to find the car, not being able to read the directions and carry out tasks, like putting together a grandchild's swing set. Then he was diagnosed with diabetes and suffered from acute attacks of anxiety. Did the anxiety come as a reaction to the awareness he was truly ill? Was it tied to the forgetting? Or was anxiety something he'd always felt but was now unable to hide? At times his voice wavered and the area above the top lip whitened and flattened on his bottom lip revealing emotion behind his words.

The doctor explains the alternatives; Alzheimer's disease, Lewy Body disease, fronto temporal dementia, normal pressure hydrocephalus, and vascular Parkinsonism. With the left hand he holds the MRIs against his body while he jabs the plastic pictures into the light box with the right hand. He shows the wife and others the enlarged ventricles, explaining that with aging the brain begins to shrink. The sulci, the noodle-like outside of the cortex has atrophied and the darker cerebrospinal fluid outlines the depressions and mounds. The spouse asks whether the brain looks like that of someone who is sixty five. The physician shakes his head and replies it looks older, 65 is still young.

The patient has none of the stiffness or rigidity that comes with PD, his arms and wrists are supple in tone. While he is slow in his movements, it is not excessive. His speech is soft, remarkably so for a big man but it carries none of the urgency that patient's with PD convey. Like the tiny shuffling steps that occasionally plague patients, sometimes the words are fast, rapidly fired. He lacks everything rapid.

They know the outlook is bleak, even though the doctor doesn't feel he has Alzheimer's. He is given a new prescription for Namenda, a drug known to curb deterioration of memory. He is already taking Excelon. Hours of neuropsychiatric testing confirmed and objectified the loss in cognitive skills, though the wife was already well aware of what was gone. He doesn't pay the bills anymore. He looks to her to tell the complete story, and she holds back details to avoid embarrassing him.