Home Alone!

When Elderly are Home Alone!!

Mr. S a quintessential gentleman of 92 summers lives alone in Chennai. After an illustrious career in the Indian Army, having occupied high positions and served actively in 3 wars, he retired to a salubrious lovingly constructed home, over 3 decades ago. Over time his home has emptied itself of his loved ones: first the children and their families migrating to live and work abroad, then the sad passing of his beloved spouse. Yet Mr. S has soldiered on- visits to his local club to play Tennis and Bridge, daily walks in the neighbourhood park, his favourite newspaper read with diligence and attention, periodic socialising with friends. Annual visits to the US where he would spend the better months of the year with the family. The ravages of time have however taken their toll. The onset of dementia about 5 years earlier, gradually made it impossible for him to continue his routine. Most of his friends have either passed on or are too immobile for him to meet frequently. The children and grandchildren visit, often taking turns, striving to attend to his every comfort. He does, however, find it increasingly difficult to place them, and to have meaningful interactions. The sad reality is that this proud soldier is in the winter of his life, home alone!

Mrs. M of 87 summers is home alone too. Widowed over a decade earlier, this mother of two successful NRI male professionals has lived alone in her Chennai apartment all this time. Her successful sons who are both in the 60’s and have made their lives and careers abroad. Spirited and sagely, she lived an independent life, commuting in autos, managing her own financial affairs, travelling abroad periodically to spend time with her children, grandchildren and recently great-grandchildren. All this came to a halt however, a few months earlier, when she was struck down by two successive neurological conditions: a stroke that affected her mobility, from which she recovered, and inflammatory neuropathy that conferred fresh disability. Yet she has shown determination to survive these setbacks, to stand up and walk again. Her children and their families have tried to visit, to spend time, to attend to her every need. But in their absence, which sadly is much of the time, the care has been provided by a loyal team of caregivers, lead by our TRIMED home care doctor and home therapy team.

Like many elders both Mr. S and Mrs. M have had several ups and downs in the months/ years that we have been privileged to care for them. It’s not just the periodic health check or blood test. The many mini crisis- episodes of breathlessness precipitated by a change in weather, sometimes by an evolving pneumonia or reactivation of asthma; falls in the bathroom, sometimes with just soft tissue injury needing an ice pack, on other occasions a fracture needing hospital intervention; urinary tract infections on occasion leaving the person confused and disoriented; the care of the home alone elder is a veritable roller coaster ride. Yet, through regular medical visits, sessions of acupressure and reflexology, Physiotherapy, cognitive retraining and supportive counselling, therapeutic massages- both Ayurvedic and Naturopathic, our team has kept these elders in good spirits, pain free, able to cope with the ravages of time and chronic disease. TRIMED’s home care thus comes with a difference; not just doctor visits or lab tests, but care that uplifts the individual, rehabilitates them, improving life quality and activities of daily living, supports the caregiver, providing help in times of crisis and succour always.

That PICA (parents in India, children abroad) syndrome is a horrific emerging reality in urban India, came to the fore last week for us. Mrs. M became acutely ill, early one morning. From arranging an ambulance for immediate hospital transport, to rushing over to assist at 5.30 AM, the TRIMED team acquitted itself remarkably well. In the end we lost the grand old lady to the inevitable icy cold hands of death; a peaceful passing with as much comfort as we could muster. Until her family living abroad could come and take charge, TRIMED was in action- participating in making arrangements for the freezer box, funereal, even the priest! We feel greatly privileged to have served Mrs. M in this way. In the end, while circumstances left her “Home Alone”, she found TRIMED and therein a caring team of professionals, willing to go the extra mile.

Frozen Music

BMMrs. P, a carnatic music teacher was admitted in an esteemed hospital based in Chennai with complaints of pricking and pulling pain in the right shoulder, difficulty in lifting her arms and gripping objects. This led to inability in doing her activities of daily living such as grooming as well as her household chores. She was a diabetic on regular treatment with suboptimal control of her sugar levels. Adding to her existing woes, she had an unsteady gait resulting in multiple falls and a sudden cessation of her music classes leading to extreme health related anxiety.

After discharge from the hospital, she underwent a comprehensive integrative clinical assessment by our team, which revealed a history of longstanding right shoulder pain which forced her to use her left hand for all her activities – quite an arduous task for someone who is not ambidextrous. The pain was persistent in spite of a course of physical therapy.

At Trimed, based on the detailed assessment, she underwent a comprehensive integrative program for peri arthritis of the shoulder for a month. This included a combination of Ayurveda, Reflexology, Mud Pack, Physiotherapy and Psychological counseling from our team of specialists. Ayurveda therapies comprised of medicated hot foments, gentle oil massages, and Physiotherapy included Electrotherapy, manual therapy, muscle strengthening with exercises – both the modalities helped in the pain reduction and loosening of stiff muscles. Reflexology helped improve blood circulation and re-activation of the nerve centres. Mud Pack helped in proper digestion and improvement of appetite. She underwent psychological counseling and was taught the Jacobson’s Progressive Muscle Relaxation technique which was effective in reducing her anxiety. Breathing exercises and Meditation along with carnatic music was also engaged as a part of anxiety and pain relief treatment.

The caregiver was educated with the ways and means to help her in recovery as a part of family counseling. The extensive support from her family played a major role in her speedy recovery.

At the end of the treatment program, mobility and flexibility was restored to her right shoulder and she was able to use it as well as before. She was back to juggling the various tasks she took pride in doing, with a flourish.

Her feedback about Trimed was that she loved coming for treatment because of the friendly demeanour and efficient service of our team. She also continued with a regular exercise regimen at home which was taught to her at Trimed.

Her words of gratitude to Trimed poured forth in the form of enchanting music, enthusing our team with a sense of pride and satisfaction about restoring an optimal quality of life for yet another patient in the true blue Trimed Way.

This TRIMED story is contributed by Ms. Angeline Vinitha, our Specialist in Psychological Counseling.

When God Closes One Door…

hopeNothing strikes greater fear in our hearts, than the possibility of lifelong disability. Sadly, modern medicine’s many advances, are yet to guarantee complete recovery from paralytic strokes, with the sceptre of lifelong disability looming large for stroke survivors.

Mrs L , an 80 year old housewife, was taken to one of Chennai’s major hospitals, after she suffered a brain haemorrhage. The event had rendered her unconscious, paralysed on the left side, unable to speak and swallow. Doctors in the hospital had done a wonderful job of saving her life- using a ventilator, tracheostomy and Ryle’s tube to allow her to breathe and receive fair nutrition. Three weeks on, when she was transferred to our care in a partner hospital, Mrs. L was barely conscious; had a tracheostomy tube, feeding tube and catheter in place, was severely paralysed on the left side (not even a flicker of muscle contraction), had excessive throat secretions and severe chest congestion.

After the TriMed comprehensive 360* assessment overseen by our neurologist and rehabilitation physician, supported by our chest and ENT physician, we optimised all her medication including broad spectrum antibiotics and nebulisation, and introduced moderate dose intravenous steroids to kickstart brain function. We also started to deliver to her, on her bedside, an integrative therapy program, including twice daily sessions of physiotherapy in the form of passive and active exercises and Naturotherapy interventions such as acupressure, acupuncture and reflexology. We started work with her family, helping them cope with her condition and setting graded realistic goals. Over two weeks Mrs. L responded well to our treatment approach; her consciousness and comprehension improved, and she began to respond and obey simple commands. We were able to make her sit with support, with which her chest secretions reduced. She regained urinary sensation and gradually her catheter was removed. She started to show response in the paralysed limbs, first flickers of contraction, later movements with gravity eliminated and then against gravity, finally against resistance. She stood with support, even walked a few steps. However, there was persistent left vocal cord palsy and a trial of tracheostomy removal failed. For this reason we also had to leave the feeding tube in place.

She was discharged to home care with a nursing partner team, and continued to undergo integrative therapy. Sessions of Ayurveda therapy in the form of oil massages and medicated foments were now introduced to improve limb power and movement along with continued physiotherapy and naturo-therapy. The psychological therapist engaged her in cognitive therapy and motivational enhancement, apart from helping her caregivers deal with their distress. Over 6 weeks, she began to walk with support , express herself with gestures and swallow small amounts of soft solids. Apart from a minor bout of aspiration pneumonia in the interim, requiring brief hospitalisation, she made good progress.

Mrs. L was back in hospital for a team review last week. During this visit her tracheostomy tube was removed, and she regained her ability to speak, albeit hoarsely. Her chest is clear and she is progressively able to swallow more each day. Her gait has improved and she walks with support. She is on course to having the feeding tube removed. She appears bright, sprightly and ready to engage with the world. Her children and grandchildren are delighted to have their beloved grandmother back, now that the TRIMED Way has rehabilitated her and restored to her, a reasonable quality of life. What is truly remarkable is that 3 months after the onset of a paralytic stroke with severe neurological deficit, this lady of 80 summers has planned and presided over her family’s Pongal (harvest festival) celebrations, with zest and happiness.

She found TRIMED’s integrated approach and in her we found the steely determination needed to conquer the sceptre of lifelong disability. Truly, when god closes one door, another does open!

The Pursuit of Wellness

credit: UND

When Mr. R the CEO of a very large enterprise first walked into TRIMED it was for non-specific aches and fatigue, no doubt the result of his highly pressured lifestyle. After a course of treatment, while he reported an improvement in his general well-being, he also shared with us his valuable impressions and insights, about how our therapeutic process could improve to address “relatively well” clients like him-self. Indeed, his frank feedback resulted in our implementing no fewer than 3 key therapeutic process developments in TRIMED. When Mr. R contacted us a few months later, seeking an urgent consultation on Sunday, it was with a whole new set of complaints. He had developed severe and unpredictable giddiness of three weeks duration, which had incapacitated him to such an extent that he had stopped working for over 10 days. Predictably Mr. R had seen specialists of every description: ENT, orthopedics, neurology, all of whom had cleared him after extensive investigations of having a serious problem, leading (much to his dismay) to his family doctor suggesting he see a psychiatrist for mental stress. Fed up with his many medical interactions, Mr. R decided to come back to TRIMED, this time with “significant’ medical symptoms; not merely for wellness, but seeking a cure.

When we re-examined Mr. R we noted three key factors.
a. Cervical spondylosis and resultant severe cervical spasm
b. Postural vertigo that came on suddenly when he moved or changed posture
c. Accompanying acute anxiety and phobia about falling that understandably accompanied the aforementioned symptoms.

Mr. R was started on a TRIMED program to address the aforementioned key factors. A combination of massage, physiotherapy (posture and balance exercises and instrumental therapy to reduce cervical spasm) and Relaxation techniques were delivered sequentially to him in our TRIMED center over 2 weeks. He did of course receive suitable allopathic medication for these new symptoms.

In a week Mr. R was feeling much better, started to travel to his office and spend a couple of hours there, bringing work home. In two weeks he stopped experiencing his giddiness episodes and was well enough for prolonged periods of time, to return to measured daily duties. A month on, he was back in his CEO saddle, multitasking, travelling extensively, managing crises in multifarious forms. Two things have changed however: Mr. R has become more measured in his approach to his work life balance. He is also regular with his practice of the TRIMED Way. Mr. R still drops into TRIMED religiously for an hour long weekly session with his favorite therapist; his way of “staying well”. Mr. R found TRIMED and together with us has made the journey from Illness to Wellness, like so many others before and after him.

From Tasmanian Devil to Mathematical Whiz

WorldAutismDayMaster S first met the Neurokrish team (later to become the Neurokrish-Trimed team) about 5 years ago. Aged three years old at the time, he was brought to us by his grandfather who had recovered fully from a stroke, under our care. S demonstrated clearly to us the features of both Autistic Spectrum Disorder and Attention Deficit and Hyperactivity Disorder. He refused to maintain eye contact, engaged in fleeting social contact which was very poorly sustained and was yet to develop any language skills of note. More disturbingly, S was profoundly hyperactive and disruptive, so much so that he could in a few moments literally tear apart a consulting or therapy room, when left alone. Needless to say his extended family, especially his mother were distraught. In our minds S bore a striking resemblance to “Taz” the adorable but disruptive “Tasmanian Devil”, then a beloved cartoon character, much loved by the kids.

Taz was offered a combination of behaviour therapy, Neurodevelopmental therapy and family counselling. He was also prescribed medication to improve attention, stabilise his volatile moods and cut down his very disruptive behaviours. Over a 3 year period, our therapeutic relationship with Taz’s family evolved; together we walked many a milestone; his first words, his play school, kindergarden, and primary school. Therapeutic holidays from drugs during summer and winter vacations; the role of extended families, maternal and paternal; expectations of the many stakeholders, parents, both sets of grandparents, uncles and aunts; teacher and school interactions; our therapeutic relationship weathered these many storms. His GI problems responded to our Naturotherapy approaches; his limbs became dexterous and his fine motor skills including handwriting skills improved with Neurodevelopmental therapy and ayurveda. Thanks to sustained behaviour therapy and parental counselling he became less disruptive, could follow parental instructions and began to sit for longer periods of time. His attendance and participation at school improved dramatically; his intuitive mathematical abilities started to shine; he learned to interact better with peers and teachers. Indeed, not only did he survive primary school, he had even topped his class in mathematics.

Recently we met our “Taz” one final time, before he migrated with his family abroad. His evolved parents had declared his condition in the immigration visa application form and sought special assistance for him aided by a detailed summary from Neurokrish-Trimed.Taz still disrupts the room a little, butts into conversations, is impulsive, slightly stilted in his conversations but now showing warmth and willingness to communicate. Taz has a combination of ADHD and the ASD spectrum and is one of our most challenging child patients ever. Yet, his remarkable progress, made possible by the wonderful therapeutic relationship our team had with his family, holds hope for many other children, affected just like he is. We do hope he will continue his progress abroad.

From S and his family we have learnt the importance of looking beyond terminology and the diagnosis. After all, mere words do not the person make!

The Man Behind the Dementia Mask !!



When the TRIMED team first encountered Mr. R aged 61 years, he was curled up on his bed in a fetal position, doubly incontinent (for both urine and faeces), barely taking in a few sips of liquid and a few mouthfuls of food each day. He was mute and had last communicated with the family in a meaningful way about 4 months earlier. According to the family he had been suffering from memory loss for over 3 years and had experienced considerable worsening in his clinical condition in recent times. His wife of 35 years was beside herself with anxiety at his declining health. It was his son, visiting from the US, moved by the plight of his beloved father, who found TRIMED.

At TRIMED Mr. R was first put through a “360* Assessment”- a measure of his TRUE HEALTH, in which our family physician, ayurved, naturopath & yoga doctor, physical therapist, clinical psychologist and nutritionist evaluated him. A detailed blood profile, brain imaging, electrophysiological tests and expert neuropsychiatry opinion from the Neurokrish team, completed our work up, revealing surprisingly few bodily aberrations that we proceeded to correct. He was started on suitable allopathic drug treatment for his condition, including anti-dementia drugs and vitamin supplements. Mr. R was inducted into TRIMED’s disease management program for dementia and over 3 weeks received nutritional therapy, ayurveda treatments, reflexology, physical exercises & mobilisation, and motivation enhancement training. Drawing him out of his cocoon in a few days, the TRIMED team soon had him up and about, taking part in his therapeutic program with increasing interest, eating well and sleeping normally. Caregiver education about dementia was effectively delivered and cognitive retraining instituted, reminiscence therapy being a particular forte among our counselling psychologists.

Today, 6 weeks on, Mr. R strode into our TRIMED centre confidently for his review appointment. With a beaming smile he greeted us appropriately with a “namaste”. He continues to have recent (and some remote) memory disturbances and to confabulate (make up) his replies. However his social behaviour and interactions are appropriate, he recognises his family members and addresses them suitably, is eating, sleeping and exercising well. Indeed he even follows “the TRIMED way” our one hour exercise protocol, with a bit of prompting. Mr. R’s son is leaving for the USA this week, a happy man. He found TRIMED for his father, and in his father TRIMED found “the man behind the Dementia mask”.

We at TRIMED are inspired every day, by people like Mr. R, their families, and the power of “modern healthcare with ancient wisdom”.

A Story Of Recovery From Brain Haemorrhage

Mr. M a farmer from an area near Chennai was first admitted in a prominent Chennai hospital with brain haemorrhage. After a two week stay in ICU he was transferred to a rehab centre. The stroke had left him confused, disoriented and apathetic with slurred speech and a weak left half of the body. Over 1 month intensive physio at the rehab centre resulted in his being more alert and able to sit up but not stand or walk. At this stage, his employer, a satisfied TRIMED customer, requested us to examine him and take him up for therapy.

Mr. M’s first visit to our Teynampet centre was in a wheel chair. While alert and oriented, he was depressed and apathetic, lacked confidence, and remained severely impaired in his activities, despite daily physiotherapy. At TRIMED Mr. M was started on whole body ayurvedic massage, acupuncture, yoga therapy, goal oriented physiotherapy, specifically gait training and psychological therapy (relaxation training and motivation enhancement). Almost miraculously, on the fourth day of therapy, Mr. M started to take a few steps with support and expressed a desire to get well. Today, after 3 weeks of TRIMED THERAPY, Mr. M is able to walk around with support, even going around the centre building with his family member assisting him. He has regained independence in all his sitting activities of daily living and is now being trained on safe transfers- bed-chair-toilet, in preparation to returning home. Needless to say Mr. M, his family, employer and treating physician, are all delighted with his progress, once thought to be unimaginable.

Mr. M is only one of many stroke patients who have made marvellous recoveries in our TRIMED THERAPY program, learning to overcome their disability. Indeed, they inspire TRIMED in its quest for excellence.

One Too Many – Tips to Tackle Multi-Medical Conditions.

Healthcare in the 21 Century has woken up to a new challenge — multi-morbidity. The presence of two or more chronic medical conditions in an individual is referred to as multimorbidity. Examples include dementia and stroke, diabetes and ischemic heart disease, hypertension and chronic kidney disease.

Multimorbidity mostly affects the middle aged and the elderly. Surveys in India have shown that over a third of all elders in India suffer from one or more chronic medical conditions. As chronic medical conditions co-occur, they lead to a cumulative burden of medical disability. Multimorbidity is most prevalent in these individuals.

Multimorbidity has significant impact on the person, family and society — in terms of healthcare costs, higher risk of hospital admissions and earlier death, poor quality of life and increased burden on the care-takers as well.

Where should we intervene?
Experts feel that interventions for multimorbidity must be primary care and community based and not confined to the specialist setting. Yet most patients with more than one chronic medical disease consult multiple specialist settings. In India where the family physician has gone out of vogue, people turn to various specialists. There is a need for integration of care, and this must begin with the family medical practitioner.

When should we intervene?
Interventions for patients with multimorbidity are needed urgently and without delay. Those interventions can be situated in primary medical care, and extend to specialist care settings. Healthcare professionals across settings, the family and society, should also be involved.

How should we intervene?

  • Interventions for multimorbidity are manifold.
  • Patient-centred: Education, support, self-management.
  • Financial: Targeting healthcare providers to reach specific targets.
  • Regulatory: National regulations designed to alter healthcare delivery and alter specific outcomes.
  • Organisational: Case management and coordination, allocation of tasks to specific members, addition of members to the team.

Best practice model in India

Our model of assessment and care for multimorbidity and chronic medical disability, developed for neuropsychiatric conditions, subsequently expanded to all medical conditions was adjudged a best practice model in the ‘World Health Report of the WHO, 2012’. In this model, both assessment and care are accomplished by an interdisciplinary team, care being rehabilitative and palliative, involving both modern and traditional medical systems, with focus on quality of life. Importantly, in the Indian context, care has to be centred in the family and community. Indeed, a series of editorials on multimorbidity in the British Medical Journal, have in recent times highlighted the need for a comprehensive approach and innovations.

Originally Published in The Hindu on 1 February 2014

Author can be reached at: Dr. Ennapadam S Krishnamoorthy

Never Mind

Caregiving can be taxing when your child suffers from a neuro-developmental disorder. But, don’t lose hope. Dr. Ennapadam S Krishnamoorthy

Children with neuro-developmental disorders (NDD) suffer from these core symptoms: learning disability, childhood epilepsy, cerebral palsy, mental retardation, attention deficit and hyperactivity disorder, autistic spectrum disorder …

What is neuro-developmental disorder?

Conditions that follow abnormal brain development and impact on motor (strength, dexterity, coordination); cognitive (intelligence, learning, aptitude); or emotional and behavioural (mood swings, temper tantrums, socialisation issues etc.) function.

Why NDD?

While some have NDD imprinted in their biological code (through genetic, hormonal, and other neurobiological factors), for many the causes lie in critical stages of development — during pregnancy, trauma, drugs, alcohol, smoking, infections, malnutrition etc. Factors affecting the child include birth trauma, infection and neonatal compromise (asphyxia, jaundice, accidents or abuse, infections, malnutrition).

Who is at risk?

The majority of NDD may be deemed to be multi-factorial, i.e. more than one genetic/ biological abnormality being responsible, with strong contributions from environmental events. In general, having a parent with a neuro-psychiatric or developmental condition may double the risk. Parental consanguinity also increases the risk.

When to suspect NDD?

Moderate to severe problems manifest early. Typically they are slow-learners in school, who find academic progress challenging.

Why should we take action early?

Children who do not receive support are likely to feel stigmatised and lose their confidence. The paediatrician should be the first port of call. The class teacher may also have valuable inputs. When either the paediatrician or the class teacher (or both) suspect a problem, more specialised inputs become necessary. Consultations include:

Learning and intelligence: clinical psychologist

Motor weakness/other brain disorders (like epilepsy): neurologist assisted by the occupational therapist

Behaviour: psychiatrist assisted by a counsellor

Language development: ENT doctor supported by speech and language therapists.

In many instances, comprehensive assessment requires a team approach. Depending on the problem, a range of laboratory tests may be required, from brain scans, EEG/ electrophysiological tests to blood and urine tests, including hormonal assays.

How should I progress once diagnosed?

The paediatrician should be your primary support. The child’s school needs to be kept in the loop. Identify a team of professionals; be consistent in your interactions and regular in follow up. Make sustainable plans and set realistic goals. Don’t focus only on the disability; your child may also have special interests and abilities. Focus on them too. Don’t be preoccupied with academic results; focus on overall development.

Care-giving is challenging and tiring; share the challenge as a family. Develop your own support networks with other parents and keep your spirit up. It’s a long road, but rest assured, there is light at the end of the tunnel.

Originally Published in The Hindu on 1 December 2013