Not easy but sometimes necessary
By Dr. Michael Gordon
With so much publicity these days about the warning signs of cognitive impairment and dementia, the availability of self-administered tests to indicate ones cognitive integrity, and brain games galore to promote “brain health”, one would think that it would be fairly easy for families to agree about what to do when an older parent/spouse begins to show signs of failing mental function.
Elder-care practitioners are aware of the difficulty and even resistance on the part of the person with evidence of cognitive decline, and often family members face the issue in a constructive manner for future planning. In one such situation that I recently dealt with, the patient was an older woman who was quite high functioning and attended my clinic with one of her two daughters. The initial referral had been for cognitive assessment and during the first year, although she had evidence of mild cognitive impairment, she did not show significant compromise of her daily functions.
A year after our first meeting, another one of her daughters, not the one I normally interacted with during appointments, contacted me. She expressed additional concerns about her mother’s function. When I discussed this with the sister that I knew, there seemed to be some disconnect. Each of these daughters seemed to be witnessing individual concerns. According to the mother, “she was fine” and could not understand the concerns. In the discussions, we did explore a few of the mum’s activities that had the flavour of some paranoia and over-suspiciousness; something I could not verify in the office visit.
With the agreement of all, a family meeting was held. I went from one adult after, having prefaced the meeting with assurances to the patient, who was present, that we were all there because of how much everyone cared about her well-being. It became clear as the stories unfolded that there was a consistency of observation of forgetfulness, repetitiveness, some lack of insight as to the deficiencies and a few episodes of safety concerns in the kitchen. Once again, the paranoid reflections were reiterated. The result—a non– threatening plan for comprehensive neuropsychological assessment and an agreement to cease driving and to utilize a very supportive family and taxis to get her to where she had to go which was a limited perimeter around where she lived. Also the plan was
to have an in-home safety assessment to explore what could be done to avoid risky situations in the future whether in the kitchen or elsewhere.
This case reminded me of the importance of open and honest communication with loved ones rather than “skirting” the issue to avoid what sometimes might be confrontational and the possibility
that each family member might see the picture differently depending
on their interactions. Also some children might be more protective of their parent’s “dignity” as they see it than others. Some children might be aware of the risks of leaving things be than others.
When concerns are expressed physicians and others such as social workers should undertake discussions with families to explore the concerns, issues and implications of cognitive impairment in a loved one: such conversations are crucial to assuring the best outcomes for those we love.
Dr. Michael Gordon is Medical Program Director of Palliative Care at Baycrest Geriatric Health Care System.