Found in Translation

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Hello (or Cheers) from London.  I am here (and in other places in the UK and Ireland) for one month of my 6-month sabbatical.  I am meeting with dementia experts to learn about their research into managing the behavioral symptoms of dementia.  There are many parallels with our work at Michigan into finding ways to better integrate non-pharmacologic treatments and target medications for these symptoms.  I suspect some exciting collaborations to come from these meetings.

But while that is the main part of the experience, there is also the experience of living and working in another country (albeit briefly).  This experience has brought to mind the movie “Lost in Translation” where Bill Murray and Scarlett Johansson roam Tokyo and contemplate their lives in the jet-lag laden fog of operating in another country. While there is no language barrier here in the UK as in the movie, every day is a new experience.

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Going to meet a colleague at a new place (while on one level involves simply going from one place to another in the city) exercises my brain’s executive function with multiple tube/other rail line changes.  It sounds simple, but timing it right, and getting on the right train and right place in the midst of hard-charging crowds can be challenging. Not to mention that I am depending on wifi for internet, so don’t have the crutch of everpresent GPS.  I have definitely had a “lost” feeling a number of times, but the feeling of accomplishment when I get to the right place is pretty nice.

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Since I have been here with my 2 teenage daughters living in an apartment, we have also had occasion to experience grocery shopping and other typical daily living tasks.  While the grocery stores and the foods in them are similar to what we are used to including self-checkout options, they are as a friend of mine put it “just a little bit different”.  For example, I found out the hard way that what looked like a fruit smoothie was in fact a type of cream alternative.  Learning to operate the combo washer/dryer in the apartment has been another growth curve.  After a week, I finally seem to have mastered it.10378277_10152546137543875_8828090909655460246_n

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Despite these minor challenges and the constant stepping out of comfort zones, what is found in translation are so many amazing experiences.  I feel like the ruts of many years of routines have been washed away in such a brief time and it is a great feeling.

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Happy Sweet and Salty Mother’s Day

There’s a lot of sweet (and rightfully so) on my Facebook feed today.  Wonderful and lovely pictures of friends’ moms and friends’ kids.  But this morning, I am feeling a bit “salty” (my favorite new coffee drink from the Songbird café here in Ann Arbor is rosemary sea salt latte—it sounds weird, but the sweet and salty flavor is wonderful and delicious).  And to me, sweet and salty captures being a mom.

Take the picture below.  Last night, I arrived home late from being at my oldest child’s crew regatta in Columbus on Friday and most of Saturday.  There was a Bath and Body Works store across from my hotel in Ohio and I picked up LOTS of hand soap (typical mom multi-tasking).  When I got home, I asked Sophia, my middle child, to put the soap in the kids’ bathroom.  This picture represents her interpretation of that request.  Salty.

Sophia's interpretation of "put these in the bathroom"

Sophia’s interpretation of “put these in the bathroom”

I am reading cartoonist Roz Chast’s hilarious and poignant  graphic memoir “Can We Talk about Something More Pleasant?” about dealing with her parents’ old age.  In depicting her parents, she certainly does not have rose-colored glasses, and shows them warts and all.  The reader gains an understanding of their personalities and how they got to be who they are.  Her mom, a retired assistant principal, tended to anger when challenged and described this as giving people “blasts from Chast”.  While it is clear that her daughter experienced this as upsetting, she is able to add humor to her perspective and has an understanding of her mother that is lovely, albeit painful.

With my family, I too possess what has charitably been called a “Mediterranean temper” (and less charitably, “being a jerk”).  I have worked on it over the years, but my children have received many “Blasts from Kales” particularly in response to “Insubordination from Kids” (see above picture).  On reflection, the blasts are not that effective, and over time, I have tried to change my ways (we’ll see how that gets depicted when they write their own graphic memoirs, likely pretty salty).

My own mom is uber-patient, kind and always there to listen (sweet).  She is a hard act to follow. However, HER mom was pretty salty.  She was one of many children born to a farm family in North Dakota and didn’t receive much attention or love her way.  When she became a mom, that got played out.  Although my grandmother could be hilarious, fun and witty, she could also change on a dime and go to bed in a huff.  Interestingly, my mom describes some of her best times with her mom (who had developed Alzheimers’) as occurring after my grandmother was placed in a Catholic nursing home in Minnesota.  Somehow my grandmother’s love for my mom was loosened and she could express it more easily.  However, she was still WAY salty: one of my mom’s favorite last memories of her mom was when a music therapist was leading the elders at the home in a rendition of “If You’re Happy and You Know It”.  My grandmother’s response?  “Shaaaad-up!!”.  It makes us laugh to this day.

And being able to laugh helps you to accept the salty with the sweet.  Happy Mother’s Day!

The Power of Being Heard

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The other day my daughter Tasia was telling me about some things going on with friends in high school that were troubling her.  I listened briefly and then immediately jumped into “problem-solving” mode.  She stopped me short, “Mom, I don’t want you to solve this for me…I just want you to listen and nod your head.”  I laughed and made some exaggerated head nods and she replied “Yes!  Just keep doing that!”.

 

The next day with my own mom,  I was telling her about an issue going on at work that was bothering me.  She listened briefly and then immediately jumped into “problem-solving” mode (Apparently the apple didn’t fall from the tree!).  I felt irritation and realized this was how Tasia must have felt–  I had actually already mostly worked out how I was going to deal with the issue but just wanted to tell my mom about it.  I wanted to be heard.  Tasia wanted to be heard.  I related all of this to my mom and we talked about how the process of “being heard” is therapeutic.

 

The following day, I found myself in clinic with a patient.  She is a very sweet woman in her 80’s who is experiencing difficulties with her husband.  You see, he has dementia.  But that is not the hardest part.  Her husband had been a domineering person before developing dementia, and now with the illness has tried to deny any problems with his function.  Her children have entered the picture in a good way to help with bill paying (he was paying the wrong amounts) and transportation (he was getting lost and insisted he should keep driving).  So, in essence, she did not need me to solve any problems for her.  But, she wanted to be heard, and even complain about him.  She loves him but his behavior has been difficult, and sometimes she feels very disgusted with him.  She knows these behaviors are part of his illness, but used to feel guilty for even voicing her “bad feelings”.  Admitting this out loud was progress for her.  It occurred to me that creating the space where she is able to express herself and say “bad thoughts” aloud has enabled her to return to the situation with more peace about it.  When she left the appointment, she gave me a big hug and said she was going to miss seeing me while I was on sabbatical.

 

And to think, all I did was listen.

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“Bad to the Bone” or Broken Brain?

On the day I was born
The nurses all gathered ’round
And they gazed in wide wonder
At the joy they had found
The head nurse spoke up
Said “leave this one alone”
She could tell right away
That I was bad to the bone
–George Thorogood, “Bad to the Bone”

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The other day, Janet Kavanagh (our Director of Program Development for the Program for Positive Aging ) sent me a link to a blogpost from the site Agingcare.com .  I looked at the site.  It has a lot of great information for caregivers, who as I have noted in a past post, have one of the world’s toughest jobs.  However, the link was to a blogpost provocatively titled, “How to Handle an Elderly Parent’s Bad Behavior” , and the post gave a “top ten” list of “bad behaviors” of elderly parents including: rage/anger/yelling; inappropriate comments; and paranoia and hallucinations.

 

All of these symptoms and others detailed in the article are extremely common behaviors seen in older people with dementia.  The text of the article actually does contain some very useful tips and does acknowledge the neuropsychiatric origins of some of these behaviors.  But, the sensational packaging is concerning and feels like “blaming the victim”.  The article (which has been widely read and has almost 60 comments from caregivers) misses a real opportunity to educate folks who skim it and do not read the details. Labeling behaviors as “bad”, when in many cases they are due to a “broken brain”, is counterproductive at best and could be a justification for elder abuse at worst. Unfortunately, in my experience as a clinician, the view of “bad behavior” is a common one, with caregivers viewing behaviors as being done to them personally and on purpose.

 

What do I mean by a broken brain?  Below is a graphic depiction (credit to the Bright Focus Foundation) of the normal brain on the left and the brain of a person with Alzheimer’s dementia on the right.  Notice the differences?

 

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And beyond the obvious and literal “shrinkage” of the brain in a person with dementia, the brain circuits that control behaviors including mood, impulse control, motivation, etc get interrupted.  New abnormal behaviors may be created.  Below is work from Sultzer and colleagues at UCLA showing brain changes in people who have Alzheimer’s disease accompanied by delusions (false beliefs like someone is stealing from them or cheating on them).  The top picture shows the brain metabolism/function of a healthy person; the middle, a person with Alzheimer’s and no delusions; and the bottom, a person with Alzheimer’s and delusional thoughts.  A red color indicates a higher metabolic rate, a yellow color corresponds to a lower rate (less healthy function).  The person with delusions shows a LOT less red compared to the other subjects. Their brain is literally malfunctioning.  Not bad behavior.  Broken brain.

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While the behaviors shouldn’t be called “bad”, the outcomes can be.  Behavioral symptoms cause caregiver burden and distress, and are among the most common reasons a person with dementia is placed into a nursing home.  But, here’s the good news.  There IS help available.  Caregivers who are experiencing problem behaviors with an elder should seek help from their doctor, starting with the PCP, and if needed, seek further referral to a geriatric psychiatry specialist .  A geriatric psychiatrist can give further help with behavioral/environmental interventions and medications.

 

The Program for Positive Aging is working with collaborators at Johns Hopkins to develop an “app” that will direct caregivers experiencing these behaviors to the right ways to deal with them in real time.  In addition, we are developing a “Caregiver College” to train caregivers in managing behaviors.  Stay tuned for more on those.  In the meantime, below are some other helpful online resources for those needing help in dealing with difficult behaviors:

 

Online Resources:

Books:

Bocce with Beth

IMG_20140219_224841If I didn’t know my Thea (Aunt) Beth was real, I would think that some writer had made her up as “the favorite Aunt” character in a cozy novel.  Warm, sweet, loving, full of hugs.  Visit her condo in Florida (2 doors down from my folks’), you get a piece of chocolate, a deconstruction of the last Downton Abbey episode, and a lowdown on all the best spots to hit in the area for boutique shopping.  She also makes the most delicious spinach squares I have ever had.  Not spanakopita for a purist, but who cares!  Raised in Alabama, she is a Greek “Steel Magnolia” (so, a “Steel Anemone”?).  She is 85, but looks and acts many years younger.

Aunt Beth is also a religious “Bocce” player.  For the uninitiated, Bocce is a game of Italian origin played with one small ball (the Pallino) and eight larger balls (Bocce singular or Bocci plural)—four for each team. The Pallino is thrown first and becomes the target. Then, each Bocce is thrown by a player with the goal of placing it as close to the Pallino as possible.  A point is scored for the team with the Bocce closest to the Pallino.  You get additional points when your team’s Bocce are closer to the Pallino than the closest Bocce of the other team.

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Aunt Beth was introduced to the sport by her Italian neighbor Camille.  Beth is now a crackerjack player who doesn’t miss her weekly league.  After many years of hearing about her Bocce nights, I decided to invite myself along.  What I found was a group of lively ladies in their 70’s and 80’s who not only have a lot of fun together, but are also fiercely competitive, and even do a bit of “trash-talking”.  Despite injuries (Barbara was sporting a sling) and surgeries (Irma had a recent hip replacement, Rhoda had a valve replacement a year ago and uses a walker), they were giving it their all.  The ruler was brought out a number of times to resolve close calls and no one was giving anything away.

At one point, there was actually a moment where they tried to draft my non-sporty mother into the league.  “C’mon!  You should join us”.  My mom demurred politely.  As the octogenarian peer pressure intensified, my mom said “you wouldn’t want me, I am completely uncoordinated”.  Not recognizing my mom’s strategy of self-effacement, my 9-year old son yelled out, “Yia Yia!  Never give up on your dreams!”  Literally LOL.  Not sure Bocce was ever on my mom’s bucket list, but Theo’s sincere cheerleading is hard to resist.  Only time will tell if my mom will buckle to Bocce.

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The ladies played for a good hour and a half.  Aunt Beth is truly a great competitor, her sweet demeanor checked at Bocce court gate.  She wanted to win and wanted it bad.  I think it slightly bugged her that we had to leave before the last game as her team was behind at that point.  And to wit, Aunt Beth called later that night to tell us (sweetly) that her team had triumphed and had won the Round.

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As a gift to the reader, here is her Spinach Square recipe.  Enjoy!:

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