Wednesday, August 4, 2010

Walking with Dementia


This weekend was to be my weekend to visit my son, Takoda, in Burlington, Vermont, where he has been attending college. Instead, he finished classes sooner than I had anticipated and used some of my United Airlines miles to fly to Hawaii to visit his girlfriend. Suddenly I had a completely free weekend, so I decided to visit Toronto where a friend was helping his mother put his father into long-term care. My friend's father had progressively deteriorating vascular dementia, meaning that his dementia had been caused by multiple strokes, each one leading to a stepwise deterioration in brain function. He had the usual risk factors hypertension, overweight, high fat diet, excess hard liquor consumption, history of long-term cigarette smoking, family history, but, of course, that doesn't make it any easier on the family when the inevitable stroke occurs. This was the long awaited weekend in which my friend's mother had finally had enough she couldn't care for her husband at home any longer. No one could blame her. He couldn't control his bowels or his bladder. He talked incessantly and understood little. He required half an hour of coaxing just to take his morning medication. The only way he could read the newspaper was to sing it, since that recruited a part of his brain that could still read. He couldn't recognize words unless he sang them. Even then, it wasn't clear whether he comprehended the words he was singing.

I was recruited to take Ian for a walk while my friend took his mother shopping. I was a bit apprehensive because I had heard stories about his aggressively accosting people and wandering into strange houses. I wasn't sure what I would do if he pooped his pants in the middle of the walk. What would people think if we were walking with poop dripping out of his shorts. Nevertheless, I kept my worries to myself like a good guest. After all, I am a geriatrician and a psychiatrist. I should be able to take one octagenarian with dementia for a walk. My friend's mother laid out the route on a map of their neighborhood one large square designed to take him past several parks and on roads that were not too busy.

My first challenge was to get Ian to the washroom before his walk. I had been strongly advised to do so to avoid mishaps on the walk. However, regardless of how hard I tried, Ian wouldn't go into the washroom and was suspicious of why I wanted him to do so. He kept suggested I go to the washroom or that I come inside and see what he could do. That sounded like more than I could handle on a Saturday morning, so I declined, abandoned the pre-walk washroom idea, and steadfastly resolved that I would muddle through whatever came. I told him in no uncertain terms that we were going for a walk. At first, he heard talk. I spoke louder and repeatedly, and he finally heard walk. I handed him his hat and his walking stick, and then he clearly understood. We stepped out of the house and preceded North along his street, walking a slight incline. His wife had warned me that he walked with the speed of a turtle, and she was not entirely wrong, though I have seen wombats in Australia move this slowly, as well as koalas who've eaten too many intoxicating gummy leaves.

Nevertheless, we had a marvelous walk and I learned much about the workings of his brain. In a fascinating way, his brain matched the patchwork that one would expect with a vascular dementia in which there were intact islands of function surrounded by much more immature brain processes. His patterings on the walk gave me some insight into how the brain of an infant or a young child might work. First, he was fascinated with trees. He kept saying, "they put them here." "They put them here." Sometimes they fall down or they take them down." He had the concept of trees being placed instead of growing on their own, and I learned later that he had been instrumental in arranging for trees to be planted along many of the streets in his neightborhood during the earlier years of his retirement. Trees, in his world, had literally been placed instead of springing naturally up from the sides of busy Toronto streets.

Then he explained rocks and stones to me. I came to realize that he was classifying stones according to their color and texture. The darker grey of the roadway was clearly a different stone than the lighter gray of the sidewalk. We walked by a college that had a low stone wall, and those irregularly shaped, roundish stones were not stones at all, but rather "things that you strike them and they go bang." Other stones were "things that you hit and they fall down." I could see his brain struggling to make classification systems to assign rock-like, stone-like objects into their appropriate container. He had another great definition of houses as "the place where the keep people in between their coming and their going." He wondered who lived in each house we passed and asked me if I knew. Of course, I didn't, having never been to this section of Toronto ever before in my life. He asked me what the people were doing inside the houses, which, of course, I didn't know either. He was very interested in the people and their relationship to the trees in the yards and wondered why the people had put each tree where it was placed. What remained, despite his severe dementia, is the incredible curiosity that seems innate to we humans. He wanted to go into houses to "see what was going on in there." He saw a mother with two children and speculated about who she was and what she was going to do with the children next, though he couldn't invent any proper nouns about what they would do next. He said, they would be "going and doing." That's what children are about, he said. "They go and do." They certainly do, I agreed.

He was also fascinated by a man who was hammering a post into the ground. "Let's ask him what he's doing," he said. "He's hammering a post into the ground," I said. "Probably he's going to hang a sign off that post." "Let's ask him what he's doing," Ian responded. Apparently he wanted to hear the answer from the man himself. He didn't want my interpretation. Here is evidence for that tendency of humans to want to prove things to their own satisfaction, to investigate phenomena on their own and not to rely upon other people's stock answers, which may or not be wrong.

When people walked or ran by, Ian would directly and loudly confront them. "Who are you?" he would say. "Where are you going?" Some people were taken aback. Others recognized the dementia within him and responded kindly and carefully. Perhaps they had relatives with dementia. Those who didn't were either defensive, explaining their right to be in the neighborhood, or worried that someone would confront them so directly. I tried not to interfere. He was showing the natural curiosity we humans have about other people where they are from, what is their motivation, where are they going, what are they doing. These were his questions about everyone we met, and his questions about the houses and what was happening inside them. Nothing drew his attention more than other people not trees, not squirrels, not houses, not cars, not airplanes, though he noticed cars and planes, and wondered about the people inside those cars and planes.

He kept asking me where I was from, equally surprised at each answer that I was from the United States. Where did you come from? I kept answering him that I had driven there from Buffalo, New York, since that was where I had been working during the week. He found that surprisingly amazing.

At the end of the day, the earth is our ultimate mother, perhaps a better mother than our own mothers. I remember a story about a friend coming upon a bear with cubs and freezing in her tracks, expecting the bear to maul her. The bear only breathed on the back of her nect and then moved away. Dementia had done more than breathe upon Ian. It had come to almost completely occupy his brain. Nevertheless, it contained mysterious teachings, messages from spirits, people that Ian could see when I could not. Now Ian was seeing and talking to spirits as if they were real people. My friend had remarked that previously he had held an obiesance to abstract Anglican Church spirits, but only as an abstract concept, not with genuine ontological status. Now his spirits and ghosts were more than real.

The message of the week is that we need to spend more time with those who are demented or psychotic, listening carefully to the teachings of their words. Throughout this week, my psychotic patients and my friend's demented father have given me great, mysterious teachings, so much more than I had expected, and so much more deeply connected to the Great Mysteries, the Spirits of the Land, and the ghosts that walk upon the earth. Perhaps dementia is really just a very slow passage into spirit world, for those who fear the sudden passage that would be thrust upon them