If you had to choose between either your mind or your body deteriorating with age, what would it be? Sometimes I feel like all of our efforts in medicine to prevent premature death from cardiovascular disease and cancer can work against us – if it isn’t our body that deteriorates, it seems that it will be our mind, if indeed we are around long enough to become ‘old’.
It really hit home to me a couple of months ago that my beautiful, intelligent 90 year-old grandmother was more than mildly demented when my mum rang in a flurry the night before a planned trip to visit me up in Clare from the South East saying “it’s really bad Mel, she didn’t even recognize dad (her husband) and wanted to call the police…she refused to come inside until the police sorted it out…what should we do?”
Grandma and grandpa on grandma’s 90th birthday
It all started about three years ago, very gradually, when grandma would repeat herself in a conversation, or get a little mixed up with which town her grandchildren were now living in and what they were doing – not necessarily demonstrative of a memory disorder at that stage, because with a few children and several grandchildren one could be forgiven for forgetting some details or getting a little confused. Yet it continued to happen and slowly got worse. At the beginning she would say, “oh silly me, that’s right, I remember now – my memory isn’t what it used to be”. As things progressed she would repeat herself multiple times in a conversation and not even realize that she was calling my mum (her daughter) the name of her deceased cousin – it wasn’t even worth correcting her because this just caused distress and embarrassment. And at least she recognized that mum was someone special to her.
Grandma does sometimes still remember new information, for example, she could not forget that her kind country GP quite rightly “took away (her) license” which she relayed to us in disgust at least 5 times in 30 minutes! The lack of insight is a difficult issue, especially if it tarnishes a long-term doctor-patient relationship. This is something I find particularly difficult in my work in general practice, and it is only going to become more challenging as I build up longer-term therapeutic relationships with people.
Later, things became a little more dangerous with grandma still at home – one day grandpa heard (although he is now somewhat deaf at the age of 95) a calamity outside of their lounge room – he went out to the kitchen to investigate and found that a pot of boiling potatoes was nearly boiled dry and was now burning on the stove top. Close call. Grandpa really stepped up though. My grandparents have always been stoic and were fiercely resistant to in-home assistance, not to mention the almost forbidden suggestion that they may need to move into residential care. However now that granny is sometimes not even recognizing grandpa, and therefore may not trust him to look after her, where does that leave us? If things reach crisis point she may need an acute admission in the country hospital whilst a plan of action – possibly residential care – is arranged. Then my ‘doctoring hat’ lights up and thinks “perhaps she has a delirium at the moment?” Could be. Maybe it’s a UTI or a chest infection (always consider water or air in the oldies). Perhaps I will check her vital signs and dipstick her urine whilst she visits? But this doesn’t take away the fact that she has dementia.
Dementia can be so devastating; usually, in the end more for the affected person’s family. It is horrible no matter how or in whom it strikes. I do however feel that it is all the more difficult when a person’s physical health is great, yet their mind lets them down – or vice versa for that matter. Not that it is any better if both body and mind are failing! Yet it’s not like it is modern medicine that has ‘kept granny alive’, as she has thankfully always been physically fit and well. It is just terribly sad that her mind is failing – and at a scarily fast rate now. I never thought it would be someone in my family who didn’t even recognize their own loved ones. I do feel fortunate to have both sides of grandparents in my life even though I am approaching my 30s, however it is difficult to see one of them deteriorate so rapidly like this. People often say that the ailments that come with ageing are “better than the alternative”, which I have found myself saying to patients at times, however I do believe that there are some situations where this is not the case. I am not an advocate for active euthanasia but I am an advocate for ageing gracefully and for quality over quantity, if at all possible.
Despite all its difficulties, there are some aspects of dementia that can be a little humorous. I have heard it said, “Alzheimer’s disease can be quite nice; you meet new people every day and can even hide your own Easter eggs!” (This quotation thanks to Dr. Gribble). There was a line that grandma said that made me crack up when mum relayed it to me. She was having a moment where she was questioning grandpa’s identity saying, “you’re not my husband, you’re an old man!” Grandpa disagreed calmly saying, “I am your husband Pat”. Grandma thought for a second in a frame of mind that believed she was 23 years of age, and then exclaimed, “well if you are my husband, you’ve aged a heck of a lot!” I’m sure she would have had quite a shock if she saw her own face in a mirror at that moment. An earlier experience of dementia I had was in the Royal Adelaide Hospital as a medical student; one of the elderly male patients with dementia was ‘sun-downing’ and a code grey was called as he was standing menacingly, brandishing a butter knife which he was waving at the nursing staff. My consultant, registrar, intern and I went to assist, and my consultant enquired of him calmly, “what’s the problem sir?” He answered with scorn in his voice, “I’ve got four problems”, and pointing his butter knife at each of us in succession, followed with “one, two, three, four!” Although it was sad that his mind was failing him and he was clearly upset, this was the moment I believe when a seed for appreciating dark humour – a survival mechanism for many doctors – was sewn in me! I couldn’t help but laugh about this after the immediate crisis was resolved.
I’m still not sure what I would choose if I had the chance – mind or body. I used to think to myself, “if I get to a ripe old age and something has to go, I want it to be my mind such that I don’t even know about it, and I am a happy demented lady where the most exciting part of my day is eating a honey sandwich”. At least that would be easy for both myself and my carers!
GreenGP 
Reblogged this on FOAM4GP and commented:
another great piece by Mel!
Thanks Minh!
Thank you. My father died with advanced Alzheimers, but it was pneumonia/asbestosis that took him. He always knew me, as his eldest child, but he often forgot who my aged Mum was (she was 79 when he died, he was 77): to him, yes, like your grandma, his wife was always about 23, so who was this strange woman he was waking up next to? Mum cared for him until the very end, it was hard; then he went into palliative care. I am so thankful to the GP and Nursing Home who treated him humanely and did not push for extreme measures to prolong his life. I KNOW he would have preferred any physical disability to not have dementia, when his life was to be taken by this terrible condition anyway. My mother at nearly 91 has been in care for 3 years because of dementia. Even though she has multiple physical problems, again, I know she would prefer to have her quick, bright mind back before having her spine fixed, or her knees, or her prolapse, or her cataracts, or..
My own opinion is, let me keep my mind, whatever else I lose. . Please, Doctor, Don’t give me heart medication, BP medication, cholesterol medication to prolong the life of my body if/when I develop dementia: if I don’t know my family, if I can’t go out in a wheelchair to the garden, I am already dead.
Thanks for your comments Helen. I tend to agree with your sentiments. It is so difficult for loved ones to see family members deteriorate with dementia, especially knowing the bright, intelligent people they used to be.