Thursday, November 19, 2009

A Burden.

I walked into the room, and I wanted to snuggle him. Before me sat an 84 year old man, dressed to the nines with a tweed blazer, corduroy pants, black loafers and white socks. Beside him sat his son, a burly construction worker whose pained, glossy eyes penetrated my soul.

"Dad's memory isn't what it used to be," the son told me and my preceptor. He spoke softly and gingerly. The old man looked straight ahead, unfazed. "He gets confused."

As the interview unfolded, we learned of a life in isolation. The man lived alone in a trailer, which he kept immaculate. It's all he had. He was disconnected from his world -- he couldn't hear well enough, see well enough, process well enough to engage. His son did all he could, and they both knew that it wasn't enough.

We assessed the pressing medical issues and developed plans for the next steps to evaluate his memory, vision and hearing difficulties. We said goodbye, and approached the door.

"Should I bother keeping on?"

My preceptor stopped dead in his tracks. Slowly, he turned to face his patient.

"Absolutely. You have to. You have so much to live for. We're going to work together to get through this. I'm here with you."

My eyes glossed over.

"Sometimes I don't know if it's worth it. I can't do what I'm told. I'm stupid. I'm useless," he whimpered. "I'm such a burden on my family."

It was a textbook list of "common concerns" of which I'm supposed to be mindful when interacting with older people. Except it was real, delivered through desperate, painful, hopeless sobs. And I didn't know what the hell to do about it.

My preceptor left me alone with the man and his family, tasked with administering a Mini Mental Status Exam (MMSE). I've seen it done several times in my forensics life and had a lecture on it in school last year, but I'd never administered one before. I was nervous.

I sat down at the desk beside him, touching my sharpened #2 pencil to the first question. Breathe. Ready. I looked up at him. His eyes were glossed over, looking at me helplessly as if he wanted me to fix him. I didn't know how.

I ransacked the archives of my brain for prototypes of experiences like this one: discouraged person looking for answers he or she expected me to have. No, not that one. Not that one. No. No. No. Yes. Flash back to the day after Thanksgiving last year. One of my Spinning students in New York confided to me after class that she was struggling with an eating disorder. She felt helpless, and thought that I might have some magical insight to end her suffering. The responsibility of being trusted to share in her burden was heavy, painful. I felt inadequate. I couldn't erase her challenges; I didn't know how. But then I had a moment of clarity. I wasn't supposed to "fix" this. I was in control of how I defined my function, and I could choose a useful one. So I started asking questions designed to help this young woman frame her challenges within the context of her goals, and to identify the cognitive structures that helped and/or distracted her. Maybe it didn't make a difference in the long run. But for at least the next 10 minutes, she felt empowered to fight. And that was enough.

"It sounds frustrating to feel like you can't remember the things people tell you..." I began.
His eyes held my gaze.
"Have you ever tried repeating back the things people tell you, to hear the instructions in your own voice?"
He looked confused.

I simulated a conversation with the man's son.
"Dad, come over Sunday at 12pm."
"You want me to come over Sunday at 12pm?"

I explained how there are different pathways in the brain that are responsible for processing things we hear vs. generating speech -- and that some people's brains work differently, and are better at some pathways vs. others. I told him that, as a medical student many years his junior, I need to engage the other pathway in order to remember stuff. He smiled. So we practiced a few more rounds with his son, and I could feel the anxious fog start to clear.

I started the MMSE.
"What year are we in?"
"You know, the date... the year?"
"2000 and..."
"Oh. 1002. I mean, 1007."
"Ok, what state are we in?"
"GREAT!" I exclaimed, far too enthusiastically. I was so eager to validate him.
"What county are we in?"
"You know, the part of the state..."


His eyes squinted, and he slammed his fist into his forehead.
"I AM SO STUPID. Stupid, stupid. I don't know anything. What am I going to do?"

I touched his shoulder.
"I understand that you're frustrated... because you expect yourself to be able to do this stuff. But a lot of people don't know their county. You don't ever have a cause to think about it in your daily life. And the thing is, the part of your brain that handles attention is affected by how frustrated you are. When you get frustrated, it doesn't work so well. So maybe if you try to be more patient with yourself and take your time, your recall will kick in. Take a deep breath and..."
"Washington County." he interrupted me.
"See? Perfect."
"You're right. It's really 'in there.'"

The rest of the exam continued. Word repetition, number counting, backwards spelling, instruction following. Most of it pretty dismal. Occasional episodes of forehead-slamming, lip-quivering. I felt awful; he felt worse.

The last step is to copy a figure of interlocked pentagons. I expected this to be painful for him. I told him that I think it'd be painful for me -- that this test is designed to assess many different domains of function, that some people just simply aren't "spatial." He began to draw.
"No... this isn't it."
"That's ok. Try again."
He tried again.
"Just one more... I can do it this time."
"Go for it."
And he went for it. Twelve more times.

When he finished those damned pentagons, he looked up at me and smiled triumphantly.
"See? I did it."

The pentagons weren't exactly pentagons. But there were 10 angles, and the shapes sort-of touched. It wasn't exactly what anyone would hope for. But from the look in his son's glossy blue eyes, it was good enough. Enough to affirm that there's nothing else I'd ever want to do with my life.


Lane said...

I always tell people I have CRS(can't remember stuff).

Just a few weeks ago I learned a trick to remember names: When someone tells you their name immediately spell the name out in your head. Its a "pathway" to remembering names.

Melissa Marotta said...

Totally! I didn't write about the part of the conversation I had with this man about not remembering names, too. That's exactly the trick we talked about. If only he can remember to try the trick...
Have a great Thanksgiving, Lane!