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Join us for a touching and insightful episode with Natasha Khalid, a geriatrics fellow, as she shares her personal experience of dealing with ICU psychosis in a loved one. Natasha takes us on a journey through her grandmother’s story of battling Parkinson’s and intestinal obstruction, and her descent into hospital-acquired psychosis. Explore the emotional toll this experience has had on Natasha, as she reflects on the power of memories and the importance of cherishing moments with loved ones. Discover the unique perspective that this experience has given Natasha as a doctor and how it has influenced her approach to patients dealing with similar conditions.

Natasha Khalid is a geriatrics fellow.

She shares her story and discusses her KevinMD article, “Remembering my grandmother in the ICU.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today we welcome back on the show Natasha Khalid. She’s a geriatrics fellow. Her KevinMD article is titled “Remembering my grandmother in the ICU.” Natasha, welcome back to the show.

Natasha Khalid: Thank you for having me.

Kevin Pho: So we’ll get into the article a little bit, but for those who didn’t listen to our previous episodes together, just briefly share your story and journey to where you are today.

Natasha Khalid: I am from Pakistan. I did my med school there, and I did my training there in general medicine. During that time, I’ve been writing as one of my ways of keeping sane, and for my love of narrative medicine, for all these six, seven years, for a very long time. Then I came to the States last year to pursue geriatrics as a fellow, so I’m training in geriatrics right now.

Kevin Pho: All right. So what is it about geriatrics that led you to that field?

Natasha Khalid: During my internal medicine training, we would see a lot of patients who were above 65, and I had a lot of people in my family as well above that age. I always thought that we needed to go to a lot of doctors for them. No one person would look into the patient as a whole. We were using one person to address a certain issue of neurology and another person to address another issue. Nobody was looking at the disease.

Geriatrics is also a very developing field, and we didn’t have many geriatricians. I think we just had one in Pakistan who had newly come up and was really busy. It’s also something not a lot of people pursue. It’s not a saturated field yet, and not a lot of people are aware of it. So geriatrics did get my interest that way, and I wanted to learn more about it. In general, I also felt that as an internal medicine person, I was seeing more patients who were in the geriatric population, so I wanted to excel in that as well and be trained.

Kevin Pho: You said there aren’t a lot of geriatricians out there. We need more people to go into geriatrics. Now, for those medical students and residents who may be listening to you now, give some reasons why they should consider geriatrics as a specialty.

Natasha Khalid: First, because it’s a very interesting field. Everybody who’s becoming a doctor or a resident has people in their own family who are in that age group, and they don’t know how to manage them, right? And a lot of people from other specialties also don’t have the expertise in taking care of them. It’s not just the disease; it’s more than that. They’re looking into the surroundings, and they’re looking into other things. Is the elderly person being abused or not? Is the elderly person getting his medications? Is he the one taking them? Is he the one driving? A lot of people are living alone. Do they have all the facilities, or do they need to be put into a nursing home? Then what are the measures that we can take to prevent that?

What can we do to prevent dementia from developing? And if somebody has dementia, what are the ways that it could be prevented from further deteriorating? There are some health assessments, a yearly follow-up with their Mini-Mental exams and so on, just to see how their mental health is going, how they are able to do their daily activities at home, and whether they need help. If they need help, then maybe you could get the doctor to help you. In a lot of areas, people are unaware.

And then, you know how we have advanced life support systems these days, and preventive medicine is on the rise, so that eventually means you’ll have a greater elderly population in the next couple of years.

Kevin Pho: So you don’t have many specialized people dealing with 80-year-olds, 90-year-olds, and older, and you do expect the population to rise in that group.

Natasha Khalid: Exactly, I feel so. It’s pretty interesting. These patients are actually very difficult to deal with as well, because most of them have Alzheimer’s or Parkinson’s. So they’re not like your regular patients who come in and usually have basic diseases, and then you deal with them. Every patient is also very complicated.

Kevin Pho: All right, so let’s talk about your KevinMD article. It’s a story that you told last year. It’s titled “Remembering my grandmother in the ICU.” Now tell us, how did this article come together?

Natasha Khalid: This article came together because I was working, and it was a very busy rotation for me. I was in the ER, I remember. During that time, she had three admissions, and these were almost weekly, and we couldn’t understand exactly what was happening. But I remember in one particular admission, when I would go, I would see her and I would sit next to her, and I knew this was not her being her usual self. I would enjoy listening to things, but then it was also very sad, because I was somebody who would see people going into psychosis on a very regular basis ever since I’ve been an intern, and I was always like, “This will get better. You know, this will get better. It is ICU psychosis. If they come out, you make sure the lights are right and the environment is right, and this will get better.” When it’s your own, it’s difficult.

And this is the first time, I think, that I was in the shoes of somebody who’s an attendant of someone going through this. So I felt like with this article, there were a lot of things attached to it, and this is how it came into writing.

Kevin Pho: You mentioned your grandmother and ICU psychosis. So what exactly happened? What happened in the hospital, and what was she like at the hospital that made the team think that?

Natasha Khalid: She presented with, you know, suddenly she had a certain deterioration, and everybody thought it was a stroke, that it was something in the brain. She was admitted, and they were going through all these tests, but then it just turned out to be something else that I don’t want to mention, and that diagnosis was just so surprising.

During that time, when I knew that all of this was happening because of a certain thing, she wasn’t being her normal self. She was talking about people who were not there. She was talking about me; I was probably in her subconscious a lot. Obviously, I’ve been one of the favorites. That is when I was actually going through this, and I hadn’t been visiting because, like I said, I had a busy rotation. So she also remembered that I wasn’t coming.

What was also surprising is that once everything was over and I came to visit her at her place, she was like, “You haven’t been coming to see me.” She also didn’t have a lot of remembrance of the fact that I was around then. I have been very close to her ever since I was a child, among all my grandparents. So I think this is also one of the reasons I wrote this, and not for anybody else. But yeah, this is how this article came to be.

Kevin Pho: So tell us about ICU psychosis. What is that, and how does one manage that?

Natasha Khalid: ICU psychosis usually happens with patients when they’re sick and they get admitted. They’re not in their usual place, so they start hallucinating, they’re under stress, and they start behaving differently. As for how it can be prevented, we usually tell people to limit the noise, to limit the lights, and to make sure that the person gets to sleep well. All of that is very difficult, because usually some places have ICUs with designated beds, but you have machines that are ringing, and you have constant activity around, which is already disturbing the patient. Sleep, nutrition, all those basic elements are being disturbed, and that results in a person behaving differently, which usually alarms the family a lot. It alarms everybody a lot.

The doctors know this is ICU psychosis, and most of the time I’ve seen it dramatically change as soon as you shift them into a personal room, where it’s just them and their families. But explaining it in that moment is difficult for the patient, and specifically for the attendant. For him to see his own loved one in that situation is difficult. However, it is a reversible situation.

I was also reading somewhere that when you have these psychoses, or whenever an elderly person is admitted and you have the first signs of such a thing, of delirium developing, then it is usually one of the things that later on predicts that the person will have dementia. Or, you know, the elderly, already being hospitalized, come out with a lot of hazards of hospitalization. Most of them come back with some problems that weren’t already there. I’ve seen that very closely with my grandmother, and I have seen that with some of my patients as well, being a geriatrician.

So yeah, preventing it is one of those common things that most of us doctors know: You limit the people going in, you limit the noise, you make sure the person sleeps, you make sure the person eats, and you make sure things resemble his routine activities.

Kevin Pho: So ICU psychosis, or other causes of delirium, of course, are fairly common in the geriatric population. Now, how did this story with your grandmother affect you as a geriatric fellow? How does that affect you as a physician?

Natasha Khalid: Every time, it’s, “OK, this will get better.” And it also reminds me of the time when I was hearing a lot of things and how they were affecting me emotionally, so I also kind of start thinking that this would be affecting the other person. So that is what happened. But, you know, when you’re in the shoes of a consultant or a doctor, at that point you think of the solution. You are not somebody who’s emotionally involved; you’re actually trying to fix the situation. So you’re putting things down as the pieces of a puzzle: solution, diagnosis.

Kevin Pho: I think now, when families come to the hospital, or their loved one or elderly loved one is admitted, is there anything that you do as a physician to help prepare the family for the potential of delirium?

Natasha Khalid: We always leave them with instructions on how they can prevent problems at home. There is a whole geriatric assessment that happens, and it usually happens in the clinic. From a hospital standpoint, we do refer them to a geriatrician. We do discuss some salient points of the 3Ds, and the referrals are made to the geriatric clinic, where the whole assessment takes place.

And I think, to the audience, I would just say: Everybody above the age of 65, go for a geriatric screen. It’s so helpful. And then maybe you could have it every year, so they can also follow how your mental development is going, whether you’re deteriorating, and whether you need some help in certain areas of life. It doesn’t have to be health; it could be just home-wise. You need help to come in once a week, or you can’t do things yourself; maybe the geriatrician would be able to help you with this. If you have problems with somebody in the house that you can’t talk about, you have them to listen to you, and maybe they can come up with a solution that can work for both. And there are a lot of times we’ve helped people that way.

Kevin Pho: So when you said that over the age of 65 you should consider a geriatric screen, what exactly would that consist of?

Natasha Khalid: A geriatric screening would consist of a lot of things. We usually start by talking about the activities of daily living and the instrumental activities of daily living. Do they take care of their finances, or is somebody else taking care of them? Driving is a very important aspect. People at the age of 90 want to drive, but again, it’s very scary, because if you are developing even the initial signs of dementia, if you have, like, the signs, you can get lost in your own surroundings, and you can end up in accidents. We’ve had patients like that. So those things are part of the screening that happens.

When we do the 4Ms, which I really like, there’s “what matters most,” so that way you also know a bit about the patient in general: what matters to them, what’s important for them, what makes them happy, whether they have their activities and hobbies, and what goals they have. That way you have a general picture of how the patient is doing, and whether or not they’re sad or depressed or something. And then you also look at their ability to remember, because then you screen them for dementia or any health hazards or any mental complications that they might have.

I feel like that is really, really helpful, because that way we could suggest things that could improve your life outcome in the coming months. We could screen you with your blood tests, for what can be prevented. We can look at your medications and deprescribe. One of my favorite things to do is to cut down all the medications that are not needed.

I remember this used to happen in Pakistan: A patient is on a set of medications, and there are many, because they’re going to different doctors, and some of them are not needed on the list. Some of them are the ones that, you know, slow cognition and cause cognitive impairment. So what we do is have conversations with the elderly and try to understand, and we try to take them off, and that really, really helped. A lot of times, our patients on follow-up have said that, OK, the memory hasn’t deteriorated, and the patient has been static or has improved. That is what really, really matters.

Kevin Pho: We’re talking to Natasha Khalid. She’s a geriatrics fellow. Her KevinMD article is titled “Remembering my grandmother in the ICU.” Natasha, share some take-home messages that you want to leave with the KevinMD audience.

Natasha Khalid: It’s for the residents who are listening: Whenever you see something that affects you or gives you a different perspective, write about it, because it’s so relatable. Like I always say, 10, 20 years from now, people will wonder how medicine was practiced back in the day and what we went through, and these stories would help with understanding, because I feel like things are developing at such a high rate. People wouldn’t know how interactions were based, and maybe some things would be similar, and some things could be different.

And it’s so relatable. Every time I read somebody else’s article, every time I’m writing my own, sometimes I go back into my own article: “Oh, this happened.” And I feel like these are the best narratives that are there in this collection.

Kevin Pho: Thank you so much for sharing your story, time, and insight, and thanks again for coming back on the show.

Natasha Khalid: Thank you.