American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, December 6, 2012

'Pleasantly demented'

Scene: Morning rounds. Six medical types, varying in station from student to graybeard, are outside a patient's hospital room.
Graybeard: Who's presenting?
Resident: Jennifer's going to. [He gives a nod to the medical student.]
Jennifer: The patient is a pleasantly demented 89 year-old female brought in last night by her family for a change in ...

Versions of this scene occur every day in America's teaching hospitals. As the population ages, we continue to hospitalize more senior citizens afflicted with memory loss and behavioral changes that constitute the diagnosis known as dementia.

The most common type by far is Alzheimer's dementia, named for an early 20th century German pathologist, who came to understand the condition as a disease that gradually and irreversibly destroys the brain. When I was a kid, we just called it "being senile," as in "Uncle Bud is senile." Looking back on it, what he had was Alzheimer's.

Alzheimer's is a huge medical challenge: There is no diagnostic test for it. We are stuck with labeling a set of symptoms and behaviors as Alzheimer's. There are characteristic patterns that differentiate Alzheimer's from other types of dementia, but at best, we're still guessing. The only sure way to diagnose it is either with a brain biopsy (usually too dangerous and invasive) or an autopsy (usually a little late to matter). Alzheimer's is progressive, which means it only gets worse–albeit at different paces for those it afflicts. It causes huge turmoil for families (particularly the caregiving children) of those affected. There's no meaningful treatment other than preparation and advance planning. [Yes, there are some pills, but let me be honest with you about them: They're worthless.]

One aspect of dementia that's particularly intriguing is typified in the dialogue above. What constitutes "pleasant dementia?" Isn't that oxymoronic?

Some of those with dementia are indeed blessed with pleasantness (this attribute is without doubt in the perspective of caregivers, but likely holds true for the patients themselves). Author Sara Davidson wondered about how her mother, who had been opinionated and challenging pre-dementia (e.g. she always sent back items at restaurants) was now cooperative with a sunny disposition: Here's a paragraph from a 2008 Newsweek article about her mother:

What had caused this reversal of personality? Did dementia bring her serenity and the ability to live in the moment--a state I've spent many hours in meditation trying to attain? It would seem that we need memory in order to hold a grudge, worry or be angry. To obsess about a problem or compare the present unfavorably with the past, we need to remember it. Yet many people with Alzheimer's do become angry, paranoid or agitated. Dr. Robert Green, who directs the Alzheimer's Disease Center at Boston University School of Medicine, says he sees patients "get more cantankerous and disagreeable. Lots of researchers are looking at these negative behaviors. But I can't recall a paper about people who get more blissful."

Like Dr. Green, I've wondered about this. There's something extra sad about those we deem to have "agitated' dementia. Patients in such a state are in a living Hell of constant anxiety, worrying those around them with no ability to remember anything calming or reassuring. The pleasantly demented, on the other hand, have a beatific ability to just "let things go" and live in the moment, as Davidson writes.

Wouldn't it be great then if we had some way to predict the patterns or perhaps help push the behavior of those sliding into dementia toward the sunny side? There's no doubt that it's easier to care for those that are kind and sweet as compared with those that are cantankerous and cranky. In no particular order, here are questions that spring to mind about this situation (researchers, get your pencils ready):

--How much does our pre-dementia disposition impact our disposition with dementia?

--Does how we behave when we have dementia represent our most authentic selves? Is it simply us with the filter off? Our guard down?

--What is the proportion of us that have "pleasant dementia" to those with agitated types?

--Do the afflicted go through stages, such as early-on more agitation from frustration as memory flickers to pleasantness when it fades altogether? Or are we simply frozen in the disposition into which we cross the threshold into dementia?

Many of us would like to know these answers. If you have a story about a loved one that you're willing to share, please do.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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