Memory Series part 2/3: safety problems in early dementia: story of Steve & Nina

[00:00:00] Dr. Mia: Welcome back to the second part of the memory series. And this episode, I'm going to talk about the common types of dementia as well as common safety issues related to when people are in the mild stages of dementia. 

[00:00:21] As I have mentioned in previous episodes, there is a difference between what doctors call Mild Cognitive Impairment and dementia. The main difference is driven by how people are doing in their daily lives. For people who have dementia, once you have excluded other possible memory mimickers, as I mentioned in the first part of this three-part memory series, in episode five; once doctors have excluded other potential confounding factors for memory, and think that memory issues are due to a primary abnormality in the brain. 

[00:01:09] I'm going to tell you about the story of Steve. Steve and his wife, Nina came to see me in our memory clinic because Nina has noticed that Steve has been having a lot of what seems to be hallucinations. Steve for years has been acting out his dreams at night, where he would have vivid dreams, something like he's running or walking, he may act them out and accidentally hit Nina in bed. In fact, Nina has sleep in a separate room because Steve is frequently acting out his dreams. He woke up in the middle of the night and seems to think that there is a dog on their bed. When Nina checks out the bedroom, there is no dog. Steve seems to think that he needed to go walk the dog. 

[00:02:12] Nina also noticed that Steve is developing symptoms that really reminds her of her father who was diagnosed with Parkinson's disease before he passed away. He seems to be shuffling his gait a lot. A couple of times, he almost tripped. But thankfully, he did not have a serious fall that resulted in any broken bones. By the time that Steve and Nina came to see me, I thought that based on Steve's symptoms of the visual hallucinations, as well as neurologic exams does show signs of Parkinson symptoms, I diagnosed steve with what's called Lewy body dementia. 

[00:03:06] Lewy body dementia is actually one of the four common causes of dementia. It gets its name because of an abnormal protein that collectsin the brain called Lewy bodies, which can be seeing under the microscope. And these Lewy bodies can affect tremors, slowness in movement, shuffling and walking. The major difference between Lewy body dementia and Parkinson's dementia is that people with Parkinson's dementia tend to have motor symptoms like trouble walking or a tremor for years before they start having memory problems and hallucinations. For Steve, however, his hallucinations and his Parkinsonian symptoms all seem to happen around the same time within a few months of each other. Because Lewy body dementia is less common than Alzheimer's dementia, it is not as well known, but it can produce very significant problems in one's daily life. 

[00:04:23] In Steve's case, Nina mentioned that she was noticing that he was having driving problems . Steve has always been a very safe driver. He has never really had any accident. But more recently, she has noticed that his car has some bumps and scrapes on the car . And when she asked Steve about these bumps and scrapes, Steve cannot remember what happened. When Nina drove with him as a passenger, she noticed that he was shifting lanes very quickly without turning on his car signals and seem to tailgate people, even though they were not in a rush to go somewhere. 

[00:05:10] One day, Nina overheard Steve talking to someone on the phone. And she had overheard him giving someone his social security number. Immediately Nina told Steve to hang up. Steve unfortunately fell in a scammers phone call, where they pretended to be the social security agency and said that there was something wrong with his social security number and needed to verify this information with him. Unfortunately scams for money are oftentimes targeting older adult. Because of this phone call, Nina had to contact Social Security Agency to get him a replacement social security card. 

[00:05:59] I'm going to come back to Steve's story to talk about what I encourage Nina to do, but before I do that, I want to mention some other common types of dementia. Vascular dementia is another very common cause of memory problems. In fact. Vascular dementia also has a lot of overlap with Alzheimer's dementia. People who have vascular dementia typically have had quite a lot of small strokes or major strokes. They usually have a number of what we call vascular risk factors: things like high blood pressure, heart disease, high cholesterol, diabetes. They may have been previous or current smokers. They may have rheumatologic conditions like rheumatoid arthritis that put them at a higher risk of chronic inflammation. People who have vascular dementia, the classic presentation is that someone has a stroke and then their memory is not as good after the stroke. But unfortunately, in many people, small strokes could be completely asymptomatic, meaning they really didn't have any sudden weakness, trouble speaking or weakness on one part of their body. But when one checks a brain MRI, you can see a lot of small strokes that may have happened in the past. People who have vascular dementia, the main treatment is to try to control vascular risk factors. In older adults, an irregular heart rhythm called atrial fibrillation is also very common. Because the heart does not beat regularly, small blood clots may develop in the upper chambers of the heart that then travel to the brain. 

[00:08:19] Aside from vascular dementia, frontal temporal dementia is another relatively common type of dementia. However frontal temporal dementia typically present in people who are younger, in their late fifties or early sixties. The behavioral variant of frontal temporal dementia, can really affect someone's personality and their behavior. One of my patient, unfortunately, had very severe symptoms of constantly wanting to eat, from the time he wakes up in the morning, until the time he goes to bed even after eating multiple meals a day. He is constantly feeling hungry. It took a while for him to be diagnosed with frontal temporal dementia. But his insatiable appetite contributed to his other medical problems of diabetes. 

[00:09:21] The four major types of dementia are Alzheimer's dementia, vascular dementia, lewy body dementia, and frontal temporal dementia. There are other more rare types of dementia that I'm not going to talk about during this episode. For the sake of clarity. Alzheimer's being the most common type of dementia, which oftentimes have a lot of overlap with vascular dementia. Alzheimer's dementia can also have significant overlap with Lewy body dementia. Frontal temporal dementia can have two variants. One that tends to have more trouble with language. And the other tends to have more problems with changes in one's personality. 

[00:10:10] So coming back to Steve, who I mentioned earlier, who probably Lewy body dementia because of his problems with vivid visual hallucinations. All dementias can have hallucinations later on in the disease course. The Lewy body dementia tends to be the one that has pretty early signs of vivid hallucinations. 

[00:10:39] I had to talk with Nina in private about some safety issues related to Steve's mild lewy body Dementia. Because of his problems with visual spatial memory on memory testing as well his as well as problems with executive functioning where planning or sequencing multi-step instructions, I was very worried about Steve's ability to drive. The small bumps and scrapes on his car that are notexplained, suggest to me that he may be having trouble parking or trouble navigating with his car that he is not reporting to Nina. And the Steve's case, I made a report to the North Carolina Medical Review program. 

[00:11:39] That is a program which may be different depending on which state you are in. In North Carolina, you can make an anonymous report to someone's driving. And then North Carolina DMV will send a packet of information to the person that you reported . They will receive a packet in the mail that they have to take to the doctor, such as an eye doctor or their primary care doctor, or their neurologists to complete, in order to continue to have their driving privileges. If they do not complete the paperwork, oftentimes there are criteria to revoke someone's license. In Steve's case, because he has been such a good driver, and that I was not testing him on the road, he really wanted to prove to us and to Nina that he is driving safely. So I referred him to a local occupational therapist who conducts an on the road, driving evaluation. I will list in the show notes the association of occupational therapists that do driving evaluations. Unfortunately, many of these driving evaluations are not covered by Medicare or commercial insurances and have to be paid out of pocket. But this could be a very worthwhile expense to verify that someone is safe driving on the road, even if they have mild memory problems. It is a liability if when if an older adult gets into an accident, and there's a question of safety on the road. 

[00:13:38] In regards to Steve answering the scammer's call, I encouraged Nina to obtain a durable power of attorney, which is different from a healthcare power of attorney. A durable power of attorney give someone, full authorities to manage another person's assets. Because Nina is already Steve's wife, she had a lot of access to their joint financial accounts already. The durable power of attorney allows family members to have full control over someone's finances, especially if the person who has memory loss may have poor judgment, and still think that they have the ability to manage their finances when they do not. 

[00:14:34] While Nina was setting up the durable power of attorney with an elder law lawyer, she also called her bank and set a limit to withdrawals from Steve's debit card. She signed up for alerts from from their bank, as well as other online identity theft alerts. She reported the scammer to the social security agency. I will also link their reporting form online as well as some common financial safety tips for older adults. As I mentioned earlier, Nina had to get Steve a replacement social security card. She had to go through a lot of paperwork to get his social security changed because the scammers. The four M's are usually what I talk about with family members when people have mild dementia. And we already talked about two of them: Money and mobility specifically driving. The other two are medications and meals. I'm not going to talk about meals during this podcast because that's usually the easiest one to supplement from family members. Nina and Steve already have a system of setting up their pill boxes together every week and she knows by looking at the pill box, whether steve has taken his medications. Some sort of pill box alarm system can be very helpful for people who have memory problems and live alone, where their family members may be able to set Up a pill box for the week or for two weeks. I will also link that in the show notes. Unfortunately in Steve's case, he did not pass the occupational therapist's driving evaluation , as a result of that the occupational therapist reported to the North Carolina DMV and his license was revoke d. Steve was understandably frustrated by this. But with time, Steve allowed his wife, Nina to drive him around. This can be particularly difficult for older men to give up driving, even if the DMV revokes their license and the family is stuck in the difficult position of having to physically remove the car or hide the keys or sometimes make the car accidentally not work. But sometimes the person who has mild memory loss is able to figure it out how to get around this, even if they're not actually safe driving on the road. 

[00:17:38] I hope you enjoy this jam packed episode about common but difficult safety issues in people with mild dementia. Please share it with people you love. Leave me a review on apple podcast and tune in next time for the last part of this three part memory series.