MGordon_MD
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Jun 12, 2009, 10:27 AM
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By Dr. Michael Gordon
A few years back a patient was sent to me with a likely diagnosis of Alzheimer’s disease, but the family doctor was insecure about starting one of the newer treatments for it, given that the literature was somewhat ambivalent about the drug’s effectiveness. He knew that I supported its use, despite the fact that many of my colleagues credited my positive views to an inherent optimism rather than substantial evidence of benefit shown in standard cognitive scores.
Yet, I could not help but believe the families of the patients who often recounted important improvements with the medications, despite little evidence of real change in the scores of standard cognitive tests. Nor could I explain the disparity, other than to assume that the test may have been an inappropriate measurement tool, even though it had been one of the standards used in the drug evaluation process.
The patient and her husband were concerned because she was losing her abilities in English. German was her mother tongue, and she was reverting back to it more and more. She was especially experiencing difficulty reading books in English, which had been one of her favorite activities for the forty years she had been in Canada.
During our initial meeting, we spent a great deal of time talking about literature—a favorite subject of mine—and, clearly, she was well read and able to discuss a wide array of books she had read in the past. Since I was familiar with many of them, I could attest to her knowledge of and fluency with them. It was newer literary challenges that were causing the problem: she said she had stopped reading the book review section of the newspaper many months before because the reviews no longer made that much sense, and she was unable to remember afterwards which books might be of interest to her.
After discussing the potential benefits and side effects of the various medications for cognition and the skepticism about them expressed by some observers, she eagerly agreed to try the medication. I gave her a prescription for the drug and arranged to see her for follow-up in three months. The week before I saw her, I had begun reading Guy Vanderhaeghe’s novel The Last Crossing. By chance, the book had been reviewed in the book section of one of the local newspapers the weekend before my clinic. I had some problems getting into the book because of the number of characters. However, the characters become clarified as the book progresses and, already, I was becoming enthralled with the story. The book review commented on that very aspect of the book and encouraged readers to persevere because the quality of the book would make it worth their while.
That clinic afternoon, the first-year family medicine resident working with me as usual examined the patient on my behalf before our review together. He came into my office, very excited. “She can’t wait to see you! You are going to be very happy. I read your note and I have never seen anything like this, though, granted, I have not seen many patients with Alzheimer’s disease who have been put on this medication. Two months ago, my supervisor expressed doubt that the drug was really worth using and gave me an article from the United Kingdom to read that shed a very negative light on this whole class of drugs.”
We entered the room together and there she was, sitting with her husband, patiently waiting to see me after having spent quite a while with the resident who had re-administered the mental status examination (it took him rather a long time because he had yet not done this very often in his training). The score was substantially higher than evidenced on the previous visit. I looked at the patient and, after the niceties of greetings had been exchanged, realized that this might be a “teachable moment” to demonstrate to the resident the importance of collateral support for impressions that are often outside the standard mental status measure. In my view, these are at least—if not more—important. I looked at the patient, who was sitting next to her husband, a semi-retired academic.
“So, have you been able to reading anything in English?”
She nodded “Yes.”
“What have you been reading lately?” I asked.
She smiled and said, “Yes, last month I started reading again and have continued to do so.”
“So what is your latest?”
“I started a book two weeks ago, which I found a bit hard to get into, but now I am actually beginning to enjoy the story. The writer has a long complicated name, Van der bilt—no, that is not it. Van der haven? No, but something like that; it’s a bit of a funny name.”
“Vanderhaeghe. Is that it?” I asked.
“Yes, that’s it! A book about a crossing—The Last Crossing. Yes, that’s it—a very interesting book. I am about halfway through it.”
I looked quizzically at the husband who nodded in agreement, so I continued the interview with questions about some current events and newspaper reports, which she accounted for quite accurately.
“I use these questions at least as much as the formal mental status examination to give me an idea of real, meaningful function,” I explained to the resident. We agreed to continue the treatment, and, over the next two years, until she started deteriorating again, our book discussions continued as a means of monitoring her progress. In fact, she would often bring me a book to read that she had enjoyed herself.
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Dr. Michael Gordon is Medical Program Director, Palliative Care Baycrest Geriatric Health Care System in Toronto, Canada and Professor of Medicine, at the University of Toronto. He is co-author with Bart Mindszenthy of Parenting Your Parents.
Parenting Your Parents is available in bookstores and online at: Indigo-Chapters, Amazon and Barnes & Noble. It is available in a US edition: Parenting Your Parents: Support Strategies for Meeting the Challenge of Aging in America.
For bulk orders email info@dundurn.com. Call: 416-214-5544 or Fax: 416-214-5556
Dr. Gordon is the author of the engaging memoir Brooklyn Beginnings: A Geriatrician's Odyssey, published by I-Universe.
Brooklyn Beginnings is available in bookstores and online at: Indigo-Chapters, Amazon.ca, Amazon.com, Barnes and Noble and I-Universe
Visit Dr. Michael Gordon's website.
(This post was edited by MGordon_MD on Jun 12, 2009, 10:43 AM)
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