“Where did I put my glasses …?”

Matthew Pravetz, OFM Features

As part of its series on health and wellness, the HNP Wellness Committee offers information and guidance on dementia. This piece was written by a friar who is a clinical anatomist.The last Wellness Committee article, “Choosing a Psychotherapist,” appeared in the Feb. 17 issue of HNP Today.

When we first entered the Order, especially if it was in the pre-iPhone years, no one needed the bells and whistles, which these gizmos provide, to remember what to do next. Multi-tasking and thinking on the run were not a problem. Now every so often (or more often than we like), the real dilemma is just finding the iPhone! Or maybe it’s your keys, or the eyeglasses, or saying hello to what’s-his-name?

When doing so many things at the same time, fatigue, distraction and, indeed, age may cause occasional forgetfulness; this is quite normal. However, significant forgetfulness, such as repeating a question many times and not realizing that it was already asked, is not.

This, the first of two articles about dementia awareness, will explain signs and causes of different kinds of dementia. Dementia describes a group of symptoms that includes short-term memory loss, confusion, the inability to problem-solve, or to complete multi-step activities. There can be changes in personality or bizarre behavior. You may even see things that are not there.

Rearranging the Hand We Were Dealt
Previous articles of interest by the HNP Wellness Committee as well as the “Well Fed Friar” workshop emphasized taking control of our lives, particularly our emotional and physical health. Personally and in community we can re-arrange the playing cards of personal health that we were dealt. We can even get rid of a wild card or two, if that’s what we really desire. There are some things we do, or habits we acquire, which at first view may not seem risk factors for dementia. These are life patterns over which we still have control. Some things, however, are out of our control.

The ultimate hand we were dealt comes from our mother and father, which they, in turn, had received from their parents. Unlike playing cards, we can’t cast away unwanted genes. And so, a propensity to diabetes, hardening of the arteries (atherosclerosis), elevated cholesterol, or high (or too low) blood pressure or even depression looms as possibilities. Still, they can be controlled and held at bay. 

Smoking tobacco, we know, is dangerous to lungs but can also affect the brain resulting in demented behavior. Alcohol use in moderate amounts (especially red wine) can have protective effects, while large amounts place us at significant risk for health ailments including dementia. While these are personal challenges, they are also a test for the friars with whom we share fraternity.

Signs, Symptoms and Science
People with dementia may not be able to think well enough to do normal, previously easy-to-perform activities, such as getting dressed or eating. Just the mention of the word dementia makes us think of loss of control or even mad-hatter behavior. But, it more frequently shows up subtly, while doing the normal activities of daily living. It’s not simply forgetting about time, but being unaware of time or date. There may be a subsequent lack of initiative and then loss of it. It is not just rambling around trying to find the car keys, but rather putting the keys in an unusual place — like the freezer. 

Matt Walton, a writer for the New York Times, recently described his mother’s first sign of Alzheimer’s advancement in “Holding Fast, Letting Go.” She was out in the car to shop. She suddenly stopped, realizing that she had no idea where she was or what she had originally set out to do. He said that, “it was the lack of mooring, the collapse of space and time, the disintegration of purpose that had brought her to tears and made her pound the steering wheel in anger that day.” At the beginning, you may suspect that something is very wrong, and it makes you angry.

Dementia is not a specific disease. Popular wisdom equates dementia with Alzheimer’s disease. Alzheimer’s is just one of many causes, including stroke or tumors, that can bring on dementia. The process of diagnosing dementia has become more accurate in recent years, and specialists are able to determine if there is a problem, the severity, and often, the cause of the dementia. 

Occasionally, there may be a combination of causes, some of which may even be reversible. It typically takes time to monitor a person for a proper diagnosis to determine the course of treatment. Deciding whether the cause is a reversible condition or not guides the treatment and care for the affected person and family. While drugs cannot cure dementia or repair brain damage, they may improve symptoms or slow down the process.

Memory loss is a common symptom of dementia, but memory loss alone does not mean you have dementia. People with dementia have serious problems with two or more brain functions, such as memory and impaired language or judgment. Dementias are often grouped together by what they have in common, such as the specific part of the brain that is affected or whether they get worse with time (progressive dementias). 

Some dementias, such as those caused by a reaction to medication or an infection, can be turned around with treatment (reversible dementias). It is not unusual after certain surgical procedures, such as coronary artery bypass, that there is temporary confusion or even loss of recent memory.

Reversible vs. Progressive Forms of Dementia
Under certain conditions, brain cells are “insulted.” The cells are not injured or killed, but struggle to function because they are either temporarily deprived of something necessary for metabolism or they may be physically compressed. Usually this results in vision or hearing problems, but there may also be subtle demented behaviors. 

Some infections or immune problems (as in Lyme disease), or hormonal abnormalities (thyroid, hypoglycemia, too much or too little calcium, impaired absorption of B vitamins), even some products released into the blood from an improperly functioning heart or lung, or a reaction to some prescribed medication, any of these could result in demented behavior. Tumors in the brain can compress healthy tissue and can also impede brain function while not damaging the nerves that make up the wiring of the surrounding brain. 

But, after sugar, calcium or vitamin levels are brought to an acceptable range, frequently the mental confusion will diminish. Even shrinking or removing brain tumors that do not affect the global functioning of the brain may reverse the dementia behavior.

On the other hand, there can be changes in the brain cells that are irreversible, the exact cause of which is not known and can usually only be confirmed on brain tissue examination upon death. The brain of a person with Alzheimer’s disease has two types of changes: clumps of a normally harmless protein (beta-amyloid) and fibrous tangles which are made up of an abnormal protein (tau). 

The symptoms, which begin after age 60 (but can be earlier), include confusion. Over the next seven to 10 years, they progress with a decline in cognition, language, judgment and eventually, even with loss of ability to move. Alzheimer’s is the most common cause of dementia in people age 65 and older.

Anthonian_December_2006As previously mentioned, not all dementia is a result of Alzheimer’s disease. In another type of irreversible dementia, Lewy body dementia, protein clumps appear resulting in symptoms that come and go. But, there will also be tremors (like in Parkinson’s disease), kicking and thrashing during sleep or visual hallucinations while awake which are not found in Alzheimer’s. 

Irreversible damage in the brain deprived of oxygen (stroke) in younger people, say at age 40, can result in personality changes and progress to language and behavioral problems (Ischemic Vascular dementia). These symptoms can begin suddenly if you have high blood pressure, previous heart attacks or infections on heart valves.

Now What Do I do? 
Everyone has an occasional “bad day” when you’re just not yourself. Usually you can tell when that happens, and so can the brothers with whom you live. Living in the friary with a brother whose dementia is leading to inadequate nutrition, reduced hygiene, not taking medication, and problems sleeping will ultimately bring about personal safety challenges.

A follow-up article will discuss what you might do if you suspect that your own bewilderment with forgetfulness may be a sign of not just normal misplacing but the beginnings of dementia. It will also provide some suggestions as to what to do for the friar in the community who may be progressing in his dementia, including coping mechanisms for the other members of the community.

— Fr. Matthew is a professor of anatomy at New York Medical College in Valhalla, N.Y. He was featured in the December 2006 issue of The Anthonian in an article called “Anatomy of a Friar Professor.”