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.
Labels: Alzheimer's, dementia, GlassHospital, guest post, John H. Schumann, patient communication
posted by John Schumann, MD at
9:00 AM
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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.
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
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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.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about
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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.
FutureDocs
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
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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
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physician, and offers behind-the-scenes portraits of hospital
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an
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William Hersh, MD, FACP, Professor and Chair, Department of Medical
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David L. Katz, MD, MPH, FACP, is an internationally renowned
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Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of
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Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites
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MD
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Michael Kirsch, MD, FACP, addresses the joys and challenges of
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Elaine Schattner, MD, FACP, shares her ideas on education, ethics
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Mired in MedEd
Alexander M.
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blogs about medical education.
More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice
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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
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evidence-based medicine tools, personal information and knowledge
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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,
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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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