One - Disclaimer: There are no pharmaceutical sponsors for this talk.The information I will share is my opinion.It is based on my experience, and my readings of journals and articles and books, some of which I will recommend to
Two – Dementia is a scary word and it can sound like a horror movie coming to your home or it can even sound like a
death sentence, but I hope you’ll wait because there is hope.We’re
going to take a closer look at how to find hope and understanding.But first…
Three – I want to tell you a true story about my postman, Mr. Bob Post.Mr.
Post was a kind and gentle man, loved by everyone.Picture the postman in Dagwood.
Mr. Post was about to turn 65, he suicided with a gun shot wound to the head, leaving no note.
Slide Four – Why am I a psychiatrist?
if Mr. Post had seen a psychiatrist, or a geriatrician, or a neurologist, or elder law attorney, he likely would not have
suicided or needed to suicide.He should have been treated with the dignity his
exemplary life had earned.
Five - At the time of Mr. Post’s suicide, I was merely fifteen years old.Naturally,
I was curious.My mother, may God rest her soul, held a steady position at the
neighborhood gossip fence.Rumor had it, she confided in me, that Mr. Post had
been accused of inappropriately touching a little girl on his mail route and would likely be facing charges.
was in the 1940’s. The meals I had eaten for approximately fifteen years,
Mr. Post had eaten for approximately 65 years.A great deal of fatback and lard
biscuits.We learned later that this caused hardening of the arteries, now known
as atherosclerotic plaques of the arteries, causing what we now know to be vascular dementia.Something different from the Alzheimer dementia, but very close in its symptomatology.
fifteen years of age, 65 looked old, very old.To me, that meant senile dementia,
touched in the head, and I knew that Mr. Post got a bum deal.A broken brain
propelled a totally out of character behavior, yet it was completely unrecognized by his family, the community, and my family.
Was I born to be a psychiatrist?
Six -We are born with eyes and ears to see, hear and observe and a brain to
understand.Not with a mathematics or psychiatry brain.
must use all of your faculties to learn as much as you can, to understand the dementias and the rigors and intricacies of
caregiving.The sooner you start, as you’re doing now, and the more you
invest in learning, the more capable and successful your caregiving will be.So
what you don’t learn in this series, please get books, read, and learn.I’ll
name some for you now:
A Pocket Guide for the Alzheimer’s Caregiver by David C. Potts, M.D., and Ellen Woodward Potts
The 36-Hour Day by Nancy L. Mace, M.A. and
Peter V. Rabins, M.D., MPH
Embracing Dementia by Ellen Marie Edmonds
story. In 1965, I was in the general practice of family medicine in North
Augusta, SC.My father was in middle Georgia and he turned 65, having
enjoyed fatback and lard biscuits and butterbeans all those years.Additionally,
he was diabetic and hypertensive.Those are risk factors for dementia.He had become a respected minister by that time.One day he
stopped to get his shoes shined.The shoe shiner put the wrong polish on my dad’s
shoes and in an instant my father punched him hard to the head.As soon as I
heard it, I knew the diagnosis - vascular dementia with behavioral changes.That
was the official beginning of his dementia trip, which lasted seven years before a large CVA (cerebral vascular accident)
or stroke took him on to the next world.
Seven – A dementia principle, as a general rule, is the same as a business principle.The last one hired is the first one fired.The last thing we learn is
the first thing we forget.Let’s take a closer look at that.
infant very quickly realizes when it is uncomfortable, when it’s hungry, when it’s thirsty, when it’s hurting.The infant signals those discomforts.It
wants to be warm, or fed, or have milk, or be held.The infant begins to realize
it is dependent on someone so that it calls for that person.Later the infant
wants and demands independence.He smiles and beguiles.He learns social skills to get his way and then ever increasingly learns complex judgment.
basically of any type, starts at the outer edge of judgment and progressively marches destructively through our mind, ultimately
back to the infant stage of being totally dependent to just wanting to be comfortable.The last things to go are touch and sound, both of which are initiated while in the womb.
dementia goes very quickly, even in a few short years.Other may go from to 12 years or even longer.The average is around seven years.We
have better medicine now than we did in the past and it is getting better all the time, even getting close to potentially
Eight - There are ten recognized early warning signs of Alzheimer dementia.I’ll
memory loss that disrupts daily life
2)Difficulties in planning or solving
3)Difficulty completing familiar tasks
4)Confusion with time or place
5)Trouble understanding what one sees, I would add,
6)New problems with words in speaking or writing
7)Misplacing things and losing the ability to retrace
8)Decreased or poor judgment
9)Withdrawal from work or social activities 10) Changes in mood and personality
will not elaborate on these lists, but if there are questions about any part of them, you may ask me later.
Nine – The Four A’s of Alzheimer Disease.May I suggest that you
think of Alzheimer as a stutterer beginning with four A’s – A-a-a-alzheimer.
1)Amnesia – short-term
2)Aphasia – language
3)Apraxia – inability
to do learned tasks
4)Agnosia – inability
to recognize familiar people or objects
Slide Ten – The L’s of Caregiving
1)Live in their world
2)Love them as they are
3)Learn to value remaining
talents and gifts
4)Let them maintain structure independence
5)Listen, listen, listen
6)Laugh with them
7)Line up respite opportunities
for them and you
8)Linger over pleasant memories
9)Look past the scribbling
to the art
Slide Eleven – A Few Quick Tips
Argue.Have you ever tried, in vain, to make your malfunctioning computer work
for you?If so, you wound up mad at the computer and yourself.
change the subject.With dementia, the attention span is progressively shorter.Generally, a quick change of the subject results in them forgetting what they were
talking about.They forget where they were.
Offer them understanding and comfort.
agree to something that is outrageous.Example:Question – “When is Pop coming home?”Pop has been deceased
for months or maybe even years.Don’t say “in a little while”
or “tomorrow.”But also don’t say, “Can’t you get
it into your head that he’s dead?”Say something comforting, “I
guess it will be a surprise.Why don’t we have some tea or go for a walk?”Or whatever they like to do.Always be
favorite foods, juices, desserts.So what if it’s not health food?Who really is going to punish them by not letting them have something they really
want at this stage in life?
things about them.Are they having trouble swallowing?Are they choking?Can they chew their food?Do they need a mechanically softened or pureed food to eat?Are
they incontinent with urine or bowels?Are they shirking their hygiene?Do they have a body odor?Do they have
a urinary tract infection or pain or fever?Are they having adequate bowel movements?Are they regular?Do they appear to be
for senior scams.These are getting to be a bigger problem nowadays.One in particular is the lottery scam.They are made to feel
that they won something.I have now seen several early dementia patients who
have been scammed out of more than $100,000 before their families realized what was happening.They scam them by mail, by the internet, by phone, and by door to door, even in shopping lots, malls, stores.They are vicious smooth talkers.
favorite mother-in-law said, “I don’t. Understand.He was such a
nice man.”Then when the family went home, she called the scammer to ask
if he really was a scammer.Of course, he assured her he was not and set up an
appointment for the very next morning.
Slide Twelve – Expectations.
be hurt: “All I did for you and you’re throwing me away, you promised not to do this.”
cause hurt:You lose your temper – “You know that’s not right;
don’t be stupid!”
unexpected:A minister using a curse word or being combative.A loyal and faithful spouse or parent becoming seductive indiscriminately, even sometimes to family.Wandering away, getting lost.
“You want to put me away.You want me to die.You just want my money.You don’t care about me.People are stealing things from me.”
being recognized:This can be very hurtful.
tender moments:Can be very rewarding.
agonize over decisions:To place your loved one in a facility or not to choose
life support any longer.
maze of legal issues:Involve elder law early.They are worth the investment.
be exhausted: Read 36-Hour Day.Think about how much time it’s going to
take you to do all that needs to be done.
and or children to be too busy or too financially unable to give substantive support.Be grateful for any help you receive.
Thirteen – Listen to the Experts.
no one knows it all.Talk to as many as you can.Listen and learn.You be in charge, but be guided by reasonable knowledge
and expertise from caring professionals.Doctors, social workers, attorneys,
especially elder law attorneys, ministers, and don’t forget, hospice.They
can be invaluable.
Slide Fourteen – Treatment Goals
your treatment goals and expectations reasonable.Outcomes can be anywhere from
better than expected to an unexpected quick demise.This is for a myriad of reasons.The experts can help you understand day-to-day ups and downs.
are equipped with good, but risky medications that may slow the dementia process and help control the behavior and unwanted
impulsive actions and may improve the quality of life.The side effects are potentially
there is no cure or even prevention, but we are learning more and getting better at what we can do.
There are no miracles.Occasionally, it seems like a miracle.
the seventies, the hospital where I worked had residents.A first year medical
resident became sluggish, could barely function, was quite demented, and he was sent to me as having developed schizophrenia.My examination of him indicated he had dementia, not schizophrenia.There was no prior history of schizophrenia and he had been a bright student.My diagnosis was normal pressure hydrocephalus.We had no
MRIs at that time, but by placing air in his spinal cord, we were able to see that his brain was actually becoming compressed
because of the fluid accumulation inside his brain.A tube was placed to relieve
the pressure and he recovered and became normal.I’m not sure how normal
because he quit medicine and became an attorney.
ibuprofen.People who take this for their arthritis seem to have a protected
factor from Alzheimer.However, too much ibuprofen will destroy the kidneys.Then I guess you could do dialysis, but I am told with the new health plans, you may
not be able to get dialysis if you’re over 70.
Seventeen – Don’t Be Caught Off-Guard by Unsettling Occurrences
loved one might go into a hospital or nursing home walking in, but become confused, have difficulty sleeping, eating, walking,
and become combative or threatening.
causes.The person can’t assimilate new rules, routines, people, and surroundings.The more complex the new situation, the worse it is for the compromised brain.Think what is the difference between the home setting and the current setting?With a home-like room in a nursing home vs. an intensive care room in a hospital,
especially if tubes are coming from everywhere?
is important to recognize that when the symptoms first began, they seemed to be developing slowly, but in the latter stages,
they tend to cascade rapidly.And this might be quite confusing and unexpected
unless you looked at it prospectively.Let’s take a look at the next slide.
Slide Eighteen – The Rise and Fall of Intellect
ways to look at this.One is this graph showing the slope and gains of learning
and how it picks up and dramatically increases over time.
we start with dementia, it is the reverse.In the beginning, it is rather imperceptible.Then it becomes routinely noticeable.Then
it becomes annoying.Then it becomes problematic and interferes with life in
a major way and then there is the final cascade of failure.
make an analogy here.Suppose we think about our brain as a ten billion brain
cell machine and our favorite souped-up automobile as a ten-cylinder engine automobile.And let’s take away one cylinder, one tenth of the engine, and one-tenth of the brain.You barely notice the brain, maybe a few skips here and there.The
engine still runs pretty good with nine cylinders, up hill, down hill.Maybe
not quite as much power going up a hill.When we lose the second cylinder, we
will notice that if we are going up a hill.We would probably even take the car
to the mechanic.When we lose the third cylinder, we are back to the mechanic
and this time we are fussing.This is about the time we would take a person to
a doctor.At that time or the next time, the doctor would probably start a memory
pill, something to help concentration in memory.The car owner would want to
rebuild the engine.When we’re down to 50%, the judgment has gotten pretty
bad.Mistakes are pretty obvious and the car’s in really bad shape.At the next level, the judgment is so bad that the person becomes unruly, often combative
and the car begins to lose other systems such as the transmission.From there
on out, it’s a rapid decline with the family not being recognized, the body parts beginning to shut down.The car’s falling apart with the electrical system going and you need to trade it in and then discard
it.And the body gives up.
other point to remember.If someone has coronary artery disease and they need
to have a stint or a bypass, you need to know that it’s not in the heart as an isolated condition.That atherosclerosis is present throughout the body, including the brain.
Questions and Answers
by H.E. Logue, M.D.
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