Posts tagged: Dementia

When to Seek a Nursing Home

When is it the correct time to seek the assistance of a nursing home?  This is a monumental decision.   An initial hurdle is the public perception of nursing homes.  It is the place to go when one is ready to die.  This remains true for some, but much less than even twenty years ago.  Over half the patients admitted to Florida nursing homes leave in a better condition than when they were admitted.  Increasingly, nursing homes are fulfilling the duties of hospitals.  Most rehabilitation is now conducted in nursing homes, rather than hospitals and free standing rehab centers.  Rehabilitation is a general term for physical, occupational and speech therapy services.  In the state of Florida it would be fair to say that emergencies are evaluated at the hospital, but most of the long-term treatment occurs in the nursing home.

In the most general terms, seek nursing home treatment for a loved one when you are no longer able to care for them at home.  This statement sounds a bit obvious, but it is not obvious in practice.  Most people in the United States wait too long before seeking treatment for a loved one with Alzheimer’s Disease.  I will repeat that statement.  Most people wait too long for nursing home treatment.  This fly’s in the face of world opinion that American’s are quick to institutionalize the elderly.  Over the last twenty years, I have treated hundreds of patients whose only crime was to care for a demented loved one until they were physically and emotionally exhausted.  I have witnessed dozens of families form three shifts to care for an elderly parent twenty four hours a day, seven days a week.

An especially poignant example is a family aftercare group.  A woman tearfully described the guilt she experienced placing her mother in the nursing home.  She had cared for her severely demented mother for nearly twenty years; seriously impacting her marriage and career.  Like so many, she found herself in the unpleasant and awkward position of changing her mother’s dirty diapers.  At the time of her mother’s admission, she was over one hundred years old, and required total care for bathing, dressing and toileting.  Her tears became torrential when others in the group reflected the depth of her devotion and sacrifice.  The situation was not unusual, it was the support she received from peers of her own age that etched the story into memory.
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Another misconception is that demented elderly patients will decline rapidly in the nursing home.  It is may be awkward for family members to admit their loved one has mentally and physically improved in the nursing home.  It is easier to coordinate physician care in the nursing home.  On an outpatient basis, physicians rarely have a coordinated picture of the total clinical situation.  Said another way, Dr. A may unfortunately not be aware of what Dr. B has prescribed.  Dr. B may not be aware there is a Dr. A. .  In the nursing home, there is a master medication record, and this record is often reviewed by pharmacists to catch possible drug interactions-or just plain errors.  The nearly universal lack of coordinated outpatient care leads to many preventable iatrogenic hospital and nursing home admissions.  A potentially positive aspect of nursing home care is the increased socialization.  So many widowed and single elderly become extremely isolated, and this lack of socialization may be destructive to their mental and emotional functioning.  Family members are often surprised to the degree their loved one’s spirits have brightened in the nursing home.

A general rule of caring for a loved one is to not exhaust yourself in the process.  Once exhausted, a caretaker is largely worthless to the patient and themselves.  You will not be doing anyone a favor by working yourself to death.  Do not be deceived that nursing home placement is a sign of personal failure, or that keeping a loved one in their home will slow the disease.  Consider adult day care if you are becoming exhausted caring for a person with a progressive dementia.  Once the loved one experiences falls, becomes aggressive or escapes from the home, have them evaluated as soon as possible.  Please visit local nursing homes and develop a relationship with the ones that appear most promising.  Do not wait to evaluate institutions until the patient has an emergency-typically a fall.  Please listen to close others who tell you to lighten the workload.  We only know ourselves through the eyes of others.  A happy nursing home visitor will likely do more for the patient’s spirits than a depleted caretaker cleaning another diaper.

A Question of Alzheimer’s

There is a single question that may accurately and reliably differentiate between dementia and normal aging.  Not only is this question  potentially able to discriminate between normal senility and dementia, it may prove a powerful method to differentiate Alzheimer’s Disease from other types of dementia.

Here is the question.  How is your memory?

Perhaps this appears too simple to be elegant.  As with any rule to describe complex phenomenon, the rule only has power within specific boundaries.  For example, Newtonian physics is so powerful that it largely accounts for the success of NASA’s space program.  Newtonian physics loses most of its predictive power when the object is going very fast, or is very small.  This in no way renders Isaac Newton’s mechanics useless, rather his worldly physics is extremely useful within certain parameters.  If the observer loses sight of these parameters, then the power of the system may suffer.  A rule that holds true for all phenomenon is compelling, but it may come at the expense of explaining anything in the particular.

The boundaries that are important for this rule are predicated on the functioning of the person before dementia is suspected.  When a person is questioned regarding the status of their memory, this directly calls upon their level of self-awareness.  The awareness of self appears to be well correlated to intelligence, but again within specific parameters.  If one questions a person with mild mental retardation regarding a cognitive skill, they will likely have some idea of the meaning, but their responses will not be very accurate in relation to informants.  Questioning someone with moderate mental retardation will reveal that they do not understand abstract concepts regarding cognition.  Once low average intelligence is reached, self-awareness is typically functional.  There is a lack of evidence indicating that self-awareness increases with above average intelligence.  It may increase, but research that converges on this conclusion is lacking.  A general rule offered is that self-awareness is likely normal until intelligence falls below the average range.  As with any cognitive skill, self-awareness may be significantly greater or lesser than one’s Full Scale IQ, but it will likely be well correlated across thousands of individuals.
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The other boundary that needs to be considered is age.  It is unlikely that this question has much utility before the age of 75.  Purely as an artifact of testing thousands of patients, it is rare for someone before the age of 70 to complain about their memory.  By the age of 80, most non-demented patients of average intelligence complain about their memory.  People in their 80’s are self-aware that their memory has declined, which is realistic and insightful.  The ability to name common objects and freely recall verbal information starts to decline in our 50’s, and is very evident to ourselves and others by the late 70’s.  In addition, people who age well are typically irritated by their inability to recall and generate names for people and objects.  Even in the early stages of a senile dementia, the victim is not bothered by their poor performance, and they frequently generate external causes for their inability to name or recall.

The next time you speak with someone in their 80’s who is constantly bemoaning their memory, let them know their cognition is likely just fine!  Conversely, the next aged person with whom you speak reporting an excellent memory should be a cause for concern.  If this person is college educated and held a middle-class job, then be very concerned.  If the person is suspected to be below average in terms of education and vocation, then the answer to this question is less revealing.  Also remember that this question is less able to discriminate between normal aging and Alzheimer’s in those younger than 75.  There are many causes of poor verbal memory throughout our lifespan, but the early degradation of self-awareness is nearly unique to Alzheimer’s Disease.  This is likely the source of the question’s utility and power.

Whether it is termed the “dementia question” or the “Holzmacher paradigm” is less important than future research into the uses of this questions for clinical practice.  This single brief question may offer physicians a procedure to accurately make dementia referrals, as well as provide a simple way for caretakers to make treatment decisions.  The greatest difficulty with the question is that it appears too simplistic to be meaningful, let alone useful.  Perhaps Friar Ockham was correct, amongst competing explanations, the simplest solutions are most satisfactory.  If anyone knows of a simpler method to reliably differentiate between normal aging and Alzheimer’s Disease, please write as soon as possible.  It is hoped that clinicians will weigh in on this proposal, as my razor may have removed a bit too much.  As always, comments from any interested party are welcome.