Friday, January 25, 2019

When Is It Time to Worry about Your Memory, And When Isn’t It Time to Worry?



 Here we are circa 1980 on a ferry in San Francisco Bay around the time we were teaching memory training classes

Memory is quite probably the most common problem discussed by older people.  We did work on memory early in our careers and revisited the issue recently.  Judy’s sister Connie invited us to give talks in the lecture series at the 55-plus community where she lives.  She mentioned how many of the people she knew were concerned about their memories, and so Judy decided to give a talk about memory.   

Sixty people came out to attend the talk on a cold and blustery night two days before Thanksgiving. They were engaged and had lots of questions.  Their worry, of course, was that their everyday memory lapses – not remembering a name, forgetting where they put something, walking into a room and not remembering why they had gone there – were early symptoms of Alzheimer’s Disease. Judy explained that there are some normal and expected changes in memory with aging.  We have trouble remembering names or words because of interference. That is, by the time we reach 60 or 70 or more, we have to sort through more information to come up with the name or word we are looking for.  There is also a general slowing of cognitive processes, which affects learning and recall. Anxiety about memory can make remembering more difficult.  Some commonly used medications can increase memory problems.  But the everyday episodes of forgetting are normal and don’t indicate anything worse.

In the early 1980s, we ran memory training classes for older people.  We taught them techniques for dealing with common problems, such as learning names of people more effectively or remembering a shopping list.  We also discussed the difference between normal memory and the more disruptive changes with dementia.  At the end of the classes, people had fewer concerns about their memory.  They said, however, it was too much bother to use the memory techniques.  What they got from the class was the assurance that nothing was wrong with them.  

Today we are bombarded with information about Alzheimer’s disease and other forms of dementia.  A week does not go by without another study being reported in the media that identifies risk factors or potential ways of preventing Alzheimer’s.  Food, supplements, exercises, meditation, loneliness, social engagement, being a volunteer, having done well in high school (really!) and being married have all been identified in studies as risks for or protection against dementia.  But most of these factors have no plausible or identified link to the pathologies that cause dementia.  All the flurry of pronouncements does is place the blame on people with dementia for not living the right ways while raising everyone else’s anxiety.

There are sensible things to do.  Regular exercise and staying at a healthy weight can potentially prevent some of the pathologies that exacerbate dementia, such as cardiovascular disease.  If occasional memory problems are a bother, you can use techniques to improve how you learn and remember or that focus your attention better so that you take in and retain information more effectively.  You can write down the things you want to remember and unlike the people in our memory classes 40 years ago, you can ask Siri for help with a name or word.  Or like the people in our classes, you can decide the everyday problems are normal and then go on with your life.

There are also times to get help.  Judy always says that when you can't remember that you can't remember, it's time to get help (although it will be someone near and dear to you who makes that observation).  If your memory is getting worse over time, if you cannot hold onto a thought at all, if you can’t remember how to do something or are getting lost in familiar places, then it’s time to seek help.  

Thursday, January 3, 2019

Geriatricians

The Jules Verne carousel in Lyon, France

One of the things about being in your seventies is that you have lived in your body for a long time.  You've dealt with its strengths and weaknesses, and you've likely gone through some illnesses or injuries.  You've also dealt with doctors to varying degrees, depending on your health and your inclination.  When we were living in State College, we had warm, collaborative relationships with our providers, in part because of Judy's professional exchanges with them, but also because they knew us and our expertise and respected us for it.  We've been fortunate to have been quite healthy, and our doctors were supportive of our "less is more" approach to medications and procedures, especially because we could back it up with research.


When we moved to Pittsburgh we ran into a long-running feud between Highmark and UPMC.  UPMC is definitely the big dog in town, but our insurance through Penn State is Highmark.  So we took the doctor-dating questionnaire and were matched with a Highmark provider that was supposed to want to work to minimize medications and work collaboratively with us.  We waited four months to see her, and then in the initial 20 minute visit, we felt rushed, not listened to, and squished into a checklist-inspired box of 70-plus year olds who should take a fistful of medications to meet the insurance criteria.  Let's just say we weren't happy campers.  We were looking for more of a guide than a policeman.

After some reflection and not a little bit of frustration, we are starting over.  In discussing our treatment with our friend who is a geriatrician, it dawned on us that a geriatrician is exactly what we want.  After all, we are now geriatric.  Or as our 6 year old grandson Sam introduces us, “These are my grandparents. They are really old.”  He actually says this proudly, adding that Steve is very strong, because he goes to the gym every day.

We weren’t looking for a credential necessarily but a perspective on aging and health that characterizes geriatric medicine.  Here are the things that we believe represent the core of geriatrics:

·        -A collaborative relationship with a physician.  Geriatricians take the time to get to know their     patients and their patients’ goals.  There will be times when treatment for a health problem conflicts with goals.  A patient may make a choice to refuse treatment based on quality of life.  A geriatric physician will explain the options for treatment so that patients can make their choice.  We don’t want a physician who just ticks off boxes of things to do prescribed by our Medicare plan, but one who supports our choices.

·        -All medications have the potential for adverse side effects.  The more medications someone takes and the longer they take them, the greater the potential for side effects.  Judy certainly saw that year after year in her practice.  In fact, depression and anxiety as side effects of medications was one of the most frequent problems she saw.  One of the hallmarks of geriatric practice is “start low and go slow,” when introducing a new medication.  Another hallmark is recognizing that too many medications can be adversely affecting cognition, mood and energy levels.  Less can be more.  And sometimes lifestyle modification is the most potent medication there is.

·        -Aging involves chronic illnesses, which by definition cannot be cured.  But often it is possible to improve functioning and adaptation to an illness through rehabilitation, life style changes and home modifications.  And we would be remiss if we did not add, psychological support.

In effect, geriatric medicine does not strive to make us young again.  Any intervention has its trade-offs.  Taking an antibiotic has clear, immediate benefits that most of the time will outweigh adverse effects.  By contrast, taking medications that might prevent a stroke or heart attack for someone who has no risk factors may not be worth the possibility of adverse effects.  Some things can’t be treated or should not be treated.  For example, a little bit of hypertension may be helpful in maintaining cognitive functioning in old age.  

Having mulled on these issues, we have decided to go to a geriatrician as our primary care physician. We have an appointment in a couple of months.  The get-acquainted appointment is not 20 minutes, as was the case in our last primary care physician, but they've asked us to allow 3 hours, so we can meet with the whole team.  We’ll let you know how it goes.



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