They may not hear or see very well, and their foot hygiene is not the best. They may walk with a cane or walker, and not very fast. From the corner of my eye, I see how they shuffle their feet with an occasional stumble that would make most folks fearful of falling. They are not concerned.
They usually live close enough to family that can keep an eye on them but may not visit too frequently because of work and family pressures. They may live alone or with a spouse of 50-plus years, and in some cases, the challenges they both face makes me wonder how they get through the day.
Sometimes there is confusion about what day it is, if they took their medicine this morning or what they ate for dinner last night. In the best of situations, their spouse is doing well and makes all the decisions about the daily issues of life, taking medicine, bathing, food and running the home. That is, when they cooperate. Because sometimes they may be just plain stubborn, or they may deal with Alzheimer’s disease or a mild form of dementia. Regardless of the reason(s), this patient is between being able to understand what is happening around them, being willing to take their medications and control their behaviors to adhere to a plan to, say, heal a foot wound...and sometimes not.
They are in a category that few recognize and fewer want to talk about because it is so tough. They are a “tweener.”
According to Oxford dictionary, a “tweener” is “A person or thing considered to be in between two other recognized categories or types.”1 These patients are between understanding and controlling their environment and actions, and not being able to do so. This term can apply across multiple areas, not just medicine, to individuals or things who are “in between” two groups, individuals or things.
I first heard the word “tweener” as a child, listening to the legendary Pittsburgh Pirates announcer, Bob Prince, on the car radio while driving with my father. According to Prince, in baseball, a “tweener” was a ball hit in such a way that it landed between two outfielders even with them both running at top speed trying to catch the ball and neither able to catch it. The term seems to fit appropriately to describe those patients who are not totally able to self-care and/or comprehend our discussions but really don’t fit into the category of being unable to.
Some are fortunate because their family recognizes when they move into this in-between category and provide a situation that makes adjustments for them. For example, these folks move closer to or actually move in with their kids. Some may relocate to an adult living facility that lets them decide how they wish to live, alone or with assistance. But some “tweeners” do not have these resources. It is these folks that need to be identified so that our social services safety net can be there to catch them before they fall.
Often times patients such as these fail to have their situation recognized, and this can lead to issues of health and safety. Podiatrists can help in this process by identifying those patients who are “tweeners” and share their findings and concerns with family members and primary care physicians. Podiatrists can also be of service to their “tweener” patients by identifying and sharing information on hospital, local senior services or social service organizations that may be available to support these vulnerable patients.
We must not forget the caregivers themselves, as being the wife or husband and caregiver of a patient in these situations is not easy and can be a relentless full-time job. My experience has been that since women tend outlive their husbands, they serve as the caregiver for their “tweener” husbands more often than husbands serve as caregivers for their “tweener” wives. Sons and daughters also act as caregivers to their parents.
In many instances these caregivers suffer as much or more than do their mates or parents, but in different ways. They may suffer from feelings like guilt, inability to convince their mate or parent to “behave” properly, they worry about finances, traveling to doctor appointments, how they are going to afford medication and the ability to perform home health treatments. All too often they make frustrated attempts to get their spouse or parent to take their medicine and make healthy food choices. Many caregivers are closely involved with blood sugar control and some even have to “stick” their loved one’s finger to get a blood sample for the glucose monitor.
Some caregivers talk of their mates walking barefoot despite their reminding them it is not in their best interest to do so. They worry about their mates’ behaviors concerning their feet and I often hear caregivers of a patient seated in the visitor chair of my office say, “we talked about not doing that,” or “see, the doctor also says not to use your penknife to cut your nails.” “Please put your shoes on.” “Did you take your medicine?” or “Have you eaten anything?”
Fortunately, there are home health services that can “come to the rescue.” Unfortunately, home health tends to be for more acute care and once they depart the scene, in my experience, things seem to revert back to where they once were. Podiatrists and their staff can help by staying in contact with the patient or their caregiver to inquire about the status of a wound or dressing, or to reinforce or support for a treatment or recommendation.
Over the years, I have noted that when a patient has a significant other in their life, or a caregiver, they seem to do better than those who live alone. Could it be that the gentle, constant, loving reminders and reinforcement of good preventive behaviors that makes the difference? I believe it does, and this is especially important for this vulnerable population.
1. Lexico Powered By Oxford Dictionary. Tweener. Available at: https://www.lexico.com/en/definition/tweener . Accessed April 7, 2021.