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"You don’t know Grandma"

When the health of the author’s grandmother deteriorated overnight, physicians ascribed her condition to old age. They were wrong.

By Judith McKenzie
Internist/Palm Beach Gardens, FL

My grandmother has always been a delightful nut. Even major surgery couldn’t squelch her irrepressible nature. The first time Grandma came to our house after undergoing a radical mastectomy, a few anxious moments passed. Then she took out her breast prosthesis and put it on the kitchen counter. "I’m tired of being busty," she declared. That was the Grandma we knew. We hoped she’d never change.

But, in her eighth decade, she did change. Over a six-month period, this bright, perky lady became bedridden, incontinent, and demented. Did she have a stroke? Could it be her medication? Was she depressed? None of the numerous specialists she saw could figure it out. Eventually, she was diagnosed with polymyalgia rheumatica. Even though she was diabetic, Grandma was put on a high dose of corticosteroids, which disrupted her glycemic control but did nothing to counteract her weakness.

A CT scan showed no evidence of a stroke, but it did reveal enlarged ventricles. A neurologist tested her for normal pressure hydrocephalus (NPH) by a cysternogram. But like the other tests, this study was normal.

"Be realistic," Grandma’s doctors told us. "She’s 81 years old."

"You don’t know Grandma," we tried to explain.

My family knew that Grandma’s sudden decline couldn’t just be a result of aging. My Aunt Barbara, a retired nurse, headed the family crusade to determine what had happened.

One Saturday, a young neurosurgeon covering for the weekend came in to evaluate Grandma in the hospital. Aunt Barbara tried to express our concern, but the doctor wasn’t interested. The next day, when the neurosurgeon reappeared, Aunt Barbara appealed to her humanity. "Look, we need an ally," she said. "Will you please help?"

The doctor sat and listened as Aunt Barbara recounted the events of the past six months. Finally, a doctor was willing to consider the clues our family was trying to communicate.

"Well, your grandmother does have the classic presentation for NPH," the doctor admitted. "The nuclear medicine study could have been falsely negative."

The next day, Grandma underwent a lumbar tap. The results were almost immediate. For the first time in months, she recognized us and was more interactive. With the successive drainage of excess CSF, she was able to walk, maintain urinary continence, and communicate. Later, after the surgical implantation of an experimental, adjustable, intraventricular shunt, Grandma became fully ambulatory and lucid. She even began riding her bike around the neighborhood again. "It’s a great way to get out of doing housework," she quipped.

As an internist, I have many geriatric patients. Those patients have families that often share their concerns with me. Now, I listen with a different appreciation for the family’s perspective. I welcome their input, and as a result I find that I’m a more effective physician. After all, being a good listener is our best diagnostic tool.

Judith McKenzie. "You don't know Grandma".

Medical Economics

2001;12.