Not Treating Dementia

Of all the diseases, I am most terrified of dementia. Senile dementia is a gradual deterioration of memory, movement, and other mental capacities. It’s extremely common (especially Alzheimer’s the most prevalent etiology). It steals the very essence of your mind. Unfortunately, with no known palliation or treatment, the disease is relentless. I’ve read about the condition, but on Friday I had my first close encounter with dementia in the healthcare setting: Mrs. A, a kind 88-year-old black lady living in the city with end-stage dementia.

“Are you a doctor?” That was her first question for me, asked when the attending and I  greeted Mrs. A and her omnipresent caretaker.

“I’m the student doctor!” I replied enthusiastically, like I explain to every patient.

Her reply, was “Oh! Then I’m in your hands.” I led everyone to the exam room, and she hobbled along slowly with her walker. Her posture remained good and straight, but her gait was strikingly unsteady. She would have likely fallen without her walker.

The attending left for a call and asked me to start the interview. Mrs. A carefully lowered herself to sit in her walker. When she looked up and met my eyes, she spoke up again.

“Are you a doctor?” Hmm, same question, same inflection. She was clearly fixated on the symbol of my white coat juxtaposed by my young face and had clearly forgotten my explanation.

“Yes, I’m the student doctor!”

“Oh! Then I’m in your hands.” Hmm, same reply. I asked her how she was feeling.

“Oh, I’m as healthy as a horse!”

Except not really. I turned to talk to the caretaker, who very enthusiastically recounted a violent vomiting episode from the weekend and listed all the food items Mrs. A has been struggling to keep down. Her weight has been plummeting, a consequence of simply forgetting to eat. She doesn’t sleep well at night, naps in front of the TV during the day. She wanders around the house without the walker, risking repeating a fall.

Throughout the conversation, Mrs. A tapped my elbow lightly to gain my attention, looked me in the eye and asked with the exact same inflection: “Are you a doctor?”

I tried all sorts of replies hoping it would stick in her fragile memory. I’m the student doctor! I’m a medical student. I’m a young doctor! Yes! Mhmm. A silent nod.

Her reply changed throughout the “I’m in your hands.” “Young man! I wish you luck.” “It’s a good profession!” Something in her internal thought process was shifting every 10 minutes, but it was completely dominated by her short term memory loss. I timed the frequency of her asking that same question. 20 seconds. That’s how fast she forgot.

Pretty soon, I realized she would ask the question upon engaging in eye contact, so I resorted to just nod in affirmation and turn my head away to continue the conversation with the caretaker. It felt so backwards and non-therapeutic, but I had information to gather during the interview. And her eyes… she stared without seeing, looked without thinking. They were wide and friendly, the pupils were dilated but blurred into her dark irises. The spark of liveliness that poets espouse, gone.

Finally, at the end of the other conversation, I turned to Mrs. A — who had hardly been listening — to see if she would corroborate the story. “Oh, I’m as healthy as a horse!” was her response. She denied feeling hungry, taking naps, told me she didn’t need to use her walker. Even her own understanding of her own state was compromised. I held her hand during that conversation, and her fingers were bent out of shape from osteoarthritis, her palms were cold, and her skin was saggy, soft, papery, brittle. The skin felt ready to slough off at the slightest scrape…

How do you provide healthcare to a patient like Mrs. A? Her dementia is impenetrable. She recognizes her caretakers still, but her short-term memory is gone. She depends upon 24/7 personal care to accomplish her most basic human needs: moving, eating, voiding, sleeping. Once the attending returned (Mrs. A asked her if she was a doctor), we read the daily hypertension and diabetes logs recorded by the caretaker. Healthcare was reduced to managing silent diseases based off mmHg and mg/dL. I couldn’t help but feel like it was a thoughtless rote reaction in diligently staving off the treatable conditions that might acutely kill Mrs. A. Not once did we consider trying to recover her previous abilities. We know we can’t.

Meanwhile, there are significant costs being incurred. 24/7 personal care is expensive, both monetarily for the family but especially for the caretakers. Half the week, Mrs. A’s daughter acts as caretaker, and I don’t want to imagine what it is like to sacrifice half her life to fight an already lost battle and be responsible for her mother who doesn’t even recognize her own daughter anymore.

Yes, Mrs. A appears to be comfortable and content (or, not unhappy at the very least), but I can’t shake the feeling that she’s rendered to live as a mere shell of her previous self. It’s a state I simply can’t fathom because there’s nothing I value more now than my awareness and agency. But other than that, I don’t know… My thoughts and fears about treating dementia remain undeveloped, and I want to meet and attempt to treat more people to form more opinions.