Posts tagged: Dementia

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?

Dementia-Clean or Dirty?

Business Logo for Psychological and Neuropsychological IssuesIs it possible to find someone with a “clean” dementia?  While this sounds like a misnomer, it is intended to describe people who suffer with a specific dementing pathology, and no other complications are known to exist.  It is a form of progressive cognitive deterioration that corresponds perfectly with its diagnostic category.  Only symptoms of this particular dementia are present, uncontaminated by other forms of physical or mental illness.  Hypothetically, such a “clean” dementia should readily conform to existing treatment protocols.  When a patient consults a neuropsychologist, they expect some sort of diagnosis with treatment recommendations, and not “well, it might be this, or it might be that.”  Families often vacillate between different factors to explain the changes in behavior and cognition, such that they expect definitive answers from a professional.  It is not unusual for the patient to become agitated when the doctor invariably, stereotypically, calls for more tests before they can arrive at a definitive diagnosis.  Why can’t we just do our job?

Here is where I frustrate my audience by reporting that diagnoses are rarely simple and clear cut, and that it’s typically a disservice to the patient to arrive at a quick and dirty diagnosis.  For example, a new patient came into the office yesterday with an old severe closed head injury.  This person exhibited classic signs of a severe traumatic brain injury.  Their personality and mental functioning were permanently altered in a way that is very consistent with the pathology of TBI that I was taught in school.  The easiest route is to dazzle the family with my knowledge of traumatic brain injury, make some behavioral and medication recommendations, and then sit back until they return in two weeks.  During the course of the interview with the family and patient, it became apparent that the patient endured a cerebral vascular accident immediately subsequent to the closed head injury.  Unfortunately, this is not an uncommon occurrence after severe closed head injury, though rare in mild to moderate injuries without a period of coma.  There are aspects of the patient’s balance and overall ambulation that would be uncommon in a “clean” closed head injury.  While the patient is walking in a functional manner, they often trip and fall into objects.  Weakness in one of their arms makes it difficult to perform tasks that require two hands.  Functional impairment from the stroke is as or more important than the impairment secondary to the closed head injury.  Formulating recommendations based on one or the other diagnosis would be unsafe and unwise.  Only by thinking in terms of the patient’s holistic or overall functioning would I be able to make their life safer and more stimulating.  Stated another way, diagnoses are typically less important than the obvious difficulties the patient confronts in their environment every day.

How is a physician able to prescribe the correct medication without the correct diagnosis?  Since the Food and Drug Administration does not allow direct comparison between drugs, physicians cannot be confident that they are using the single best medication for a given illness.  While certain medications are believed by professionals to be better for organic conditions than psychiatric conditions, there is only modest support in the research for using one medication over the other.  The best clinicians tend to prescribe by side-effect; that is there are many medications that claim to do the same thing, but the risk of unwanted and possibly deleterious effects of any given medication are uppermost in their mind.  For example, the physician is weighing the benefit of two tranquilizers.  The med they typically prescribe for most neurologically intact patients causes memory and attentional impairments, and the other tranquilizer is known to have few cognitive side-effects, but may cause trouble with ambulation.  Most of us, physician or not, would avoid using the first medication in someone recovering from a closed head injury, and avoid the second for someone recovering from a stroke or movement disorder.  While this appears to make good sense, and even smacks of common sense, one has to keep in mind that common sense is anything but common.
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The common sense approach to treatment of damage to the central nervous system is driven by symptoms and their expression in the patient’s unique environment.  A diagnosis helps alleviate the anxiety of family members and the insurance industry, but in isolation, does little to assist the patient.  Medications prescribed for their main effect rather than by their side-effect may help in one area and cause problems in another, rendering little to no net gain for the patient.  Clinicians that need to find neat categories and rapid solutions will please the family shopping for confidence more that the family looking for real gains.  Lastly, even the best of treatment protocols needs adjustment.  People change over time, and the cognitively impaired are no exception.  Any intervention that has positive results for a year or more should be considered a success-even if there is a subsequent decline.  Consider periodic adjustments to behavioral and medication protocols to be necessary and expected.

To answer the initial question, it is rare, indeed, to find a “clean” dementia.  Even if the initial stages of the dementia are uncomplicated and according to protocol, the illness rarely remains so orderly for its entire course.  Patients and family members often gain confidence from hurried and decisive experts; tending to view their curt behavior as a sign of social importance.  A clinician who is unsure and vacillating about treatment options exudes less confidence to others, but may ultimately be the most concerned and helpful.  Please leave comments regarding this article by clicking on “comments” immediately below this post.

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categories Dementia, Neuropsychology, Stroke | | datetime October 30, 2010 11:31 am | comments Comments Off on Dementia-Clean or Dirty?

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