Posts tagged: Dementia

Growing Older, Not Bolder

Business Logo for Psychological and Neuropsychological IssuesThere was an initial shock in providing psychological services to nursing homes.  It was less from the environment than the unexpected nature of the patient’s comments.  Bed-ridden patients warned staff to make travel arrangements as soon as possible; do not wait until they are too old and sick.  Most believed the whole notion of the “golden years” to be a cruel myth.  The very mention of “golden years” often forced an eye roll-even overt anger.  Story after story related a lifetime of work and sacrifice, with the view of saving money to effect a pleasant retirement.  The climax of so many stories was that a serious medical problem interrupted their plans.  Despite time and money, the retiree was not going beyond their front door.

Another unexpected facet of nursing home culture was the perception of children.  So many had come to believe that their offspring were downright traitors.  The truth is that responsible children are often required to liquidate their parent’s assets to pay for medical care.  This rarely sits well with the parents.  It is especially bothersome to those with dementia, since they are unable to understand the rationale for the actions of their children.  Often such demented patients only retain the emotionally charged aspects of the message, which is typically that their home was sold beneath them.  The logical conclusion, based on the few facts they retain, is that the children want to grab their money before they die.  This is rarely the case.  It is heartbreaking for the children to perform so much work for their parent, only to be regarded as little better than a criminal.

The brooding disappointment of extreme old age is not just relegated to the depressed individuals.  The loss of independence rarely sits well with Americans.  Many cultures appear to accept this as unavoidable, but Americans do not like the word “unavoidable.”  To work and plan for decades, only to be thwarted at the last moment, strikes Americans as horribly unfair.  The experience of other cultures is that life is often unfair, and this fact does not improve with age.  The American perspective on fairness is less prevalent with the older generations.  Two world wars and a depression impacted them in a way that is foreign to baby-boomers and beyond.  It is likely that the reaction of subsequent generations to nursing home placement will be increasingly negative.  While the WWII generation is less apt to gripe about fairness, they remain extremely adverse to depending on others.

The main deterrent to a bad nursing home placement is a realistic perspective.  We all grow old and die-if we are lucky.  That sounds cruel to those outside the health care industry, but it is self-evident to those who are involved in the system.  Many individuals suffer and die while relatively young.  Perhaps the best adjustment to nursing home care is observed for individuals that were sickly in their youth, and never expected to live to a ripe old age.  These people were forced to adopt an existentially realistic attitude at a young age.  As mentioned, many cultures are happy with basic subsistence.  They appreciate the personal service in a nursing home, since such luxuries are foreign to them.  For most Americans, there are never enough staff, and they never come quick enough to suite their taste.

A change in perspective would also alleviate rancor between the patient and responsible children.  In order to liquidate assets to pay for medical care, children are  often forced to seek the paid assistance of consultants.  It would simply the process to have disinterested third parties perform this action, as part of the government benefit.  Strangely, even demented nursing home patients rarely become agitated over this process if performed by an attorney.  While the author has listened to thousands of complaints regarding the motives of the children, even one such complaint directed at an attorney cannot be recalled.  This should not be taken as an endorsement of attorneys, rather it speaks to the reduced agitation inherent in having a third party manage the assets.  Since most people cannot afford attorneys, it is necessary to make the service part of the Medicare or Medicaid benefit.

Growing older is not a right, but the benefit of a life well-lived.  Even though fifty percent of nursing home patients return home, the typical belief is that nursing homes only function as a place to die.  Often, the staff and doctors do not know who will improve, such that the patient is held in a state of suspense.  Placement within a nursing home may be the final hurdle; a concrete message that one’s life is limited and will soon be over.  How well we accept this message says not only a lot about ourselves, but also the culture that has influenced our values and expectations.  Still, all in all…it’s probably better to take that world cruise now.

Mild Cognitive Impairment

Dr. Holzmacher's Business Logo for online psychotherapyMild Cognitive Impairment seems less threatening than its predecessors; such as “organic brain syndrome” and “minimal brain dysfunction.”  It sounds more benign than terms that contain the word “brain.”  Mild Cognitive Impairment is not an actual diagnostic code, but it is a term used by researchers and clinicians.  MCI reflects cognitive changes in the elderly that exceeds normal aging, yet does not meet the diagnostic criteria for Alzheimer’s Disease.  It is important to note that people diagnosed with MCI have retained their ability to perform all activities of daily living in an independent fashion.

Mild cognitive impairment has received much attention from the research community in recent years.  The interest is focused on what percentage of those with MCI actually convert to Alzheimer’s Disease.  This is not merely splitting hairs, as it would be a great asset to know which people in this group will actually manifest Alzheimer’s Disease.  Early diagnosis will allow more time for caretakers to plan and prepare.  An early diagnosis may also avoid surprises that utilize the emergency room and/or local law enforcement.

Current estimates of those that convert from MCI to AD are under twenty percent, but the percentage varies wildly within this restricted range.  Most suspected of MCI are brought to the attention of professionals due to a decrease in verbal memory.  Fewer are referred, in this clinician’s experience, from an onset of unusual behaviors.  This is important, because many progressive dementia’s initially present with a change in behavior prior to the onset of measurable cognitive deficit(s).  Measurable is highlighted because these people may actually exhibit a cognitive decline, but it may not be detectable by the current neuropsychological tests in use.  Current lab tests and medical imaging are ineffective at diagnosing MCI, as they are ineffective at diagnosing Alzheimer’s Disease.

There are no particular medications or class of medications that could be recommended for the treatment of mild cognitive impairment.  As with Alzheimer’s Disease, exercise and keeping mentally active are likely helpful.  The beauty of mental and physical exercise is that even if it does not prevent the onset of AD, at least the person will still retain some benefit.  The early data suggests that effortful cognitive activity is more important than the passive variety.  For example, watching TV is a passive activity and completing a crossword is an effortful activity.

Once the diagnosis has been established, it is recommended to visit the neuropsychologist at least yearly.  Only a neuropsychologist will be able to accurately measure any change in cognitive skills, and differentiate the change from the effects of normal aging.  Remember that over eighty percent of people with mild cognitive impairment never manifest a progressive dementia.  The unfortunate remainder will require ongoing neuropsychological monitoring and behavioral planning.  Report any change in mental or physical functioning to the neuropsychologist and attending physician, as they are in a better position to know what is significant.  Nearly all people with mild cognitive impairment will profit from set routines and compensatory strategies.  Even though MCI sounds less threatening than its previous designations, it is still wise to monitor the disorder and treat symptoms as they arise.

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