I can usually anticipate where the conversation is going when a family member accompanying a loved one living with dementia to my clinic starts the conversations with the words, “Surely, in this world of modern medicine, there is something more we can do to halt the decline in my (fill in whichever family member is effected). Sometimes this phrase is said with a degree of anger, sometimes with anguish and sometimes with a degree of aggressiveness as if somehow I, a geriatrician, and not a neurologist or psychiatrist might be inept in my knowledge or “holding back” on some new discovery that I do not know about. Sometimes the question is accompanied by a package of internet-based articles on “new or novel” treatments for dementia ranging from megavitamins of the already known and touted category (and generally proven ineffective in the evidence-based medical literature) or a concoction with a mysterious ingredient that “doctors won’t talk about” as they work in cahoots with the pharmaceutical industry.
Usually, even though often quite time consuming, a careful explanation of the state of the knowledge of treatment of dementia of the various kinds (the most commonly defined being Alzheimer’s disease), the person can be brought back to the reality of the current state of affairs. Most times they can be brought to focus on the real challenges that will be faced as the course of their loved one’s condition declines and they must face the very difficult decisions that will ultimately occur including planning for challenging behaviours well beyond the cognitive decline and the inevitable need to plan for end of life care that almost always occurs at some point in those who reach the later stages of dementia.
I recently saw the movie, The Iron Lady that looks at the developmental and political life of former Prime Mister of the United Kingdom, Margaret Thatcher, from the vantage point of her experiencing the earlier and then later stages of dementia. It vividly portrays the impact the disease has not only on her behaviour, memory that includes a very poignant and vivid melange of past recollections and current experiences. This is something all of us working the field recognize in our patients and which we must often explain to their family members. One often hears the lament, “She can remember in great detail her sea voyage as she escaped the ravages of the war in Europe or her childhood run-in with her brother in the village in the Ukraine, but cannot remember what she had for breakfast today”.
Sometimes the intrusion of experiences from the past can cause great agitation and behavioural outbursts and sometimes can lead to warm and sometimes tearful recollections about loved ones that they think are still alive and are distraught to find that they have died. This is something illustrated in The Iron Lady when Thatcher’s daughter has to remind her mother of her late husband’s death as she struggles with emptying his clothes from the closet and donating his previous belongings that she can associate with in her memories of him that enter and leave her consciousness as she struggles to recall the events of the present.
The movie with the stunning role of Thatcher played by the incomparable Meryl Streep stirred a sense I have had previously as I observed some of the greatest or best known minds or public figures in the world afflicted by the usually devastating effects of one form of dementia or another, most often of the apparently Alzheimer type. This has helped me explain to the family