In a viewpoint published in JAMA Internal Medicine on Monday, a very clever doctor not only tells us what Van Halen’s obsession with brown M&Ms was all about, but she also compares it to elder care.
Dr. Andrea Wershof Schwartz of the Geriatrics Research Education and Clinical Center relays the legendary rock band’s tick with the chocolate candy: “Van Halen apparently used the brown M&Ms as evidence of attention to detail on the part of the concert venue,” she explains, saying she learned the story by way of an NPR report. “If the venue staff had not noticed this small detail buried in the rider, the band could not trust that the complex music system and stage had been set up correctly, that the elaborate pyrotechnics would function safely. The brown M&Ms called into doubt the stability and safety of the entire concert setup.”
Indeed, Van Halen would not hesitate to cancel a concert upon discovery of a brown M&M. So, what does this have to do with elder care?
“This tale from the entertainment industry resonates in the work we do as physicians caring for older adults: what are the analogous brown M&Ms we can notice when it comes to the care of frail patients with complex conditions?” she asks – and then answers.
Elderly people can have lots of things wrong. But a few telltale symptoms can point to much larger problems. Here’s what doctors must pay close attention to, according to Wershof Schwartz.
The Patient’s Gait
“Gait speed is an important predictor of mortality and is one of the most frequently used criteria to identify frailty,” she writes. “When we notice a patient walking slowly, it can prompt us to focus on their arthritic knees or proximal muscle strength, asking whether they require better pain control, physical therapy, or an assistive device; their balance, considering whether they would benefit from vitamin D or B12 supplementation or a home safety assessment to install grab bars in the shower; and overall fall risk, prompting an evaluation of medications that could be deprescribed or fall risk factors that could be mitigated such as orthostatic hypotension or vision or hearing impairment.”
Can They Take Their Socks On and Off with Ease?
“If we notice our patients wearing slip-on shoes year-round, or having difficulty donning socks – a task that requires balance, vision, dexterity, joint flexibility, and muscle strength – we have a second warning sign that they may be in danger of losing their independence and their ability to dress and care for themselves,” Wershof Schwartz explains.
Are They Clipping Their Toenails?
“As geriatrician Juergen Bludau instructed in Atul Gawande’s Being Mortal, for an older patient, ‘you must always examine the feet. I have been surprised how many times in my career thus far by the disconnect between how a patient is dressed and how their feet may look. Even if they have no difficulty taking off their socks and shoes, the dexterity required to cut one’s own toenails may prove more challenging,’” Wershof Schwartz quotes from the book.
“When our patients’ toenails are long…we worry about patients’ support network, caregiver burnout or inability to attend to details, or whether they have the executive function or financial resources to seek the support they need, let alone manage their medications or other instrumental activities of daily living.”