“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler






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State of January

Dementia is like a sinkhole. It erodes from within. Particularly with Alzheimer's, the social graces are preserved until late in the disease. You see someone who is clean, properly dressed, gracious and smiling, able to carry on a conversation - although they might seem a bit vague. It isn't until you start asking detailed questions that you begin to see what's behind the facade. What's there is a vacuum.

Patient Gracious Lady, GL for short, has been my patient for many years. She would sometimes be brought by a family member, but often came alone. I usually see her about twice a year, as she has been in pretty good physical health. During her appointments nothing about her demeanor said dementia or struck me as unusual. She was recently hospitalized for a fairly minor problem, but the admitting MD warned me that she had been quite confused and the family member who brought her to see me for a post-discharge visit confirmed it.

"She'll ask me a question and I answer it. Then five minutes later, she asks the same question again."

"Who's been paying her bills? Are they getting paid?" - if you suspect dementia, this is always a good question to ask as finances are one of the first things to go by the wayside. In this case though it didn't help.

"I'm paying them." It turned out that family members had been helping her pay her bills for the past several years. During this discussion, GL sat quietly with a calm smile on her face, divorced from the entire conversation.

"I'm going to do something called a mini mental state exam." This is a fairly quick test which covers vocabulary, short term memory, math and orientation to place and time. It isn't perfect as even someone with early dementia will likely get the questions right. But sometimes, as today, the results can be quite striking.

I held up a pen and she named it immediately. But when I tapped the object on her wrist and asked her to name it, it took her 45 seconds to remember that it was called a wristwatch.

Time to test location. "What state are we in?"

"January."

Oh crap, I thought. Wait a minute.

"Is it someplace like Wisconsin? Rhode Island?"

"No, those aren't right." She pondered for a while. "It's January."

I stole a look at the relative, who was looking pretty devastated. Every answer revealed another deficiency. To be brief, the maximal score on the MMSE is 30 points; she scored less than half that.

There are tests that can and should be run if you suspect dementia, to rule out medical causes. You check thyroid, vitamin B12 and syphilis titers among other tests. I ordered them, but I am not really optimistic that her problem is treatable. Her MMSE score is probably too low for her to benefit from medication.

The one blessing that I have seen in dementia is that the patients themselves don't seem to be aware that they have a problem - or if they are aware, it doesn't really bother them. When a patient comes in with a complaint of "I keep forgetting things and I'm really worried that I have a problem," you can almost guarantee that they are not dementing. It's when the family or friends bring the patient in that you have to be concerned. GL had that same calm, detached air. The good news is that she has caring family who will look after her, and I firmly believe that social interaction helps in this disease.  Still, it is not something that one would ever wish for a relative or loved one.

Labels: Medicine

posted by Dr. Alice at #