What’s Up with Mom?

Business Logo for Psychological and Neuropsychological IssuesWhat’s up with Mom?  We moved her into a new apartment over the weekend, and she is not like anything or anyone I’ve seen before.  She is so confused she has forgotten to eat; sitting and staring for hours, or up at night and wondering the hallways.  All the children take shifts supervising her, but the situation does not appear to be resolving.  It tears me up to see her like this.  What is worse, the our family is splitting down the middle; some favor keeping her in the apartment no matter what arises, and the rest believe she should be in a nursing home.  I don’t know where to turn.

This is a paraphrased narrative that I have heard literally hundreds of times.  Neurologists of old called this the “Monday Morning Disease.”  It refers to family that did not notice a loved one becoming senile until some change in their environment produced confusion.  Most families will report changes in the patient’s behavior over a one to two year period prior to an incident, only they did not ascribe them to a senile dementia of the Alzheimer’s type.

One of the earliest symptoms of Alzheimer’s to escape the notice of others is a deficit of planning.  It is not as noticeable as memory or attention deficits, yet it causes profound functional impairment.  As long as the dementia victim relies on old well-learned behavioral routines, there is minimal trouble living independently.  Once a person’s daily behaviors are upset by a move, they must develop new functional behaviors that accomplish goals necessary to live; for example, shopping for food.  In a new environment, the person lacks clues to their old behaviors, and so are at a complete loss for where to go and what to do.  Many cognitive scientists (fancy term for psychologist) conceptualize humans as planning machines.  As you read this post, you may also be thinking of what you are going to do next, and you may even formalize the steps to accomplish this goal.  Children burst with plans for what they will do after school.  Do not mistake deficient planning for a lack of energy or optimism.  Planning is a necessary cognitive skill for survival, and it is one of the earliest functions to decline in a senile dementia.
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Another early cognitive deficit is a decline of mental flexibility.  This is not to be confused with someone who is easygoing and complaint with the wishes of others.  Cognitive flexibility refers to a person’s ability to switch between mental sets; for example, glancing at a drawing and putting together a model.  It is a necessary skill we all employ every day to accomplish tasks with greater efficiency and accuracy.  It is evident while doing the dishes and answering the telephone, alternating between tasks at work, and making conversation while driving.  When this skill declines, the person is noticed to be performing behaviors that are out of character with the situation.  In my residency, the team was to discharge a patient to independent living when I noticed he had taken apart his shaver and laid it across his bed.  The patient missed several physical therapy sessions due to his insistence he had to fix the shaver.  The shaver was busted, but he could not conceive of working alternately on the shaver and his ambulation.  He became obsessed (stimulus bound) to the shaver; neglecting more important goals that he had to accomplish.  While it may appear as a failure to prioritize his goals, this unfortunate man could not accomplish the main goal because he was stimulus bound to an unimportant goal.

The early deficits of a senile dementia are subtle, yet as real and damaging to an independent existence as the deficits of verbal and visual memory.  The latter deficits are well known to the average person.  Memory skills are the main determinant of Alzheimer’s Disease in most people’s minds.  Actually, verbal and visual memory may be functional well into the disease, and these “executive” deficits of planning and flexibility may be crippling at an earlier stage of the disease.  In terms of planning the future for someone with a known or suspected senile dementia, the family should take these symptoms into account.  It reduces the probability of a Monday morning surprise.  Please leave comments regarding this post in the space provided below.

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categories Alzheimer's Disease, Dementia, Memory Disorders, Neuropsychology | | datetime January 7, 2011 4:38 pm | comments Comments Off on What’s Up with Mom?

Holiday Blues Revisited

Dr. Holzmacher's Business LogoThank God!  The holidays are over.  This is a common harangue at this time of the year.  It seems ridiculous that a time of year intended to give thanks and count one’s blessings should lead to so much tension.  Perhaps the unintended consequence is ridiculous, but the ill effects are not.  There are many reasons why people become depressed at this time of year, and here are a few.  First, the way the Christmas Holiday has been configured in America, it is maximized towards the desires of young children, as their gifts comprise the greatest slice of the economic picture.  This echoes the direction of motion pictures to offer material enjoyed by the adolescent and young adult ticket purchasers.  This is not an evil plan, to my knowledge, but the typical manifestation of a market to make the most of its opportunities.  This does not mean that it will be welcomed by all members of our society, as is clearly the case.  Listening to one’s children complain about the paucity or selection of the gifts can infuse the occasion with a sense of meaninglessness.  If you are a middle-class American, it is likely you turned in the same performance as a child.

Second, the holidays tend to bring back memories of loved ones that are no longer around.  Whether they are deceased or merely estranged is less important than the way we are affected by the distance.  There may be an unfulfilled need for this person, or a desire to make amends and reestablish contact.  Either way the affected person may be morose or even mildly depressed at a time when we are all supposed to be happy.  The expectation that one should be particularly happy during this time of year makes thoughts of loss and longing especially burdensome.

Third, what of this social obligation to be happy during the holidays?  Social demands form the core of culture, and we tend to experience feelings when we accomplish or ignore cultural demands.  Even if a person is not particularly sad during the holidays, there is an expectation of being happier than usual.  If we do not acquiesce to this social demand, we are apt to feel guilt at the lack of our responsiveness.  Another perception is anger at being subtly told how to think and feel, even if the consequences of not conforming are nothing more than disapproving looks.  The behavioral literature is bursting with examples of  how controlling another person’s behavior tends to increase the pressure to resist.  People do not like to be pushed into ways of thinking and feeling; unless they believe it was at their initiative.
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Fourth, and perhaps the least discussed, is the holidays bring us into contact with people we may not like.  Many friends and patients describe the familial and work obligations that are less than enjoyable.  Perhaps due to the social demand of being happy and friendly during the holidays, most people tend not to acknowledge this potentially unpleasant aspect of the season.  Even in the closest of family and work relationships, there are people one would rather not see more than once per year-if that!  To buck and bridle about visiting the besotted “Uncle Jimmy” runs the risk of  being branded a “Scrooge.”  See, there is even a special designation for those unfortunates who do not have the appropriate “Christmas spirit.”

What can one do to stem the tide of emotions that flood during the holidays?  The first is an automatic response to most mental health issues.  Wait.  Most of the negative emotions dissipate rapidly after the holiday season.  Watching the apparently unappreciative children enjoying their toys, and besotted Uncle Jimmy wearing your gift, tends to ameliorate the initial reaction.  January is a “git back to work” month when few expect to be particularly happy.  Nature obligingly provides cold cloudy days to accomplish all the accumulated work.  It seems a bit natural to be down in January, such that the social expectation to be joyful nearly vanishes!  As in my other posts on depression, the typical waiting period is three to six months.  If your depressive symptoms do not lessen within this time frame, it is likely that a depressive disorder has caught hold and will require professional treatment.  Fortunately for most, the negative aspects of this season fade from view as the more positive aspects take hold in one’s memory.  Please leave comments regarding this post in the section below.

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categories Depression, Psychology | | datetime January 3, 2011 11:05 am | comments Comments Off on Holiday Blues Revisited

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