CAREGIVER SURVIVAL: I HATE ALZHEIMER'S ........................................ Joseph J. Sivak MD

Sign The National Alzheimer’s Plan Petition

2012-01-31T13:57:00.000-08:00

Sign The National Alzheimer’s Plan Petition:

'via Blog this'

important.

God Bless,

joe

Your Father is Dead. Grieving Children-Fathers and Sons.

2012-01-28T10:43:00.000-08:00

It was 34 years ago today January 28, 1978, The residents of Cleveland and Buffalo and Erie PA (where I was), remember it as the "blizzard of the century". It was a Saturday Morning and the wind was howling and the mountains of snow were piling up. In Cleveland. it was and still remains the lowest recorded barometer reading in history.
I had just turned 16 a month before. On that morning, I stood in the driveway trying to jump start our car, as somehow my father in the hospital at Cleveland Clinic 100 miles away from Erie, had taken a turn for the worse. We had to somehow get the car started and make it 100 miles in the blizzard to see him. No one including myself, believed in his mortality. It wasn't magical thinking, it was just that my father the strongest, smartest person, whom could provide all forms of safety and security, like no one else in the world ever would or could.
As I stood in the driveway, that phone call came- the one that in an instant changes the course of your life- 'we didn't need to come to Cleveland now'. My Mother in a panic shouted to my sister and brother, "Dad just died."
My first thought was, "Oh no. Now what am I supposed to do?" 34 years later I am still trying to figure out the answer. It is a timeless question for the ages maybe only asked and answered in a way between fathers and sons. I do wish I would have asked him when he was on earth, but I am not sure I would have been ready for the answer then. It might be something that is demonstrated through life, a question we go back to and revisit over the life span.
In that blizzard. I knew then that life would never be the same. I wondered what it would be like for my father to be dead. Would he be all right? How could he leave us? What would the world be like now? What was I supposed to do right then and what was I supposed to do for the rest of my life?
I had a lot of questions and there was now a fundamental problem that has plagued me forever. If the most secure thing in the world -my Father , could die, then there really was nothing secure at all in the world.
I had lost part of myself and part of my identity. When you lose part of your heritage, you roots and your essence, it might figures that one would not know where they were supposed to go or what they were supposed to do from then on in the future.
My life has never been the same, The world has always been a bit more uncertain, and maybe a little cruel, without that safety and security. His loss has colored every aspect of my life. All the success and all the failures, all my roles as a man have been touched by this loss. From father to husband, brother, uncle, friend. personally and professionally. All of the good and all of the hardships, since he died, oh so many hardships, the pain, the sorrow and agony, which I mostly as a man have kept to myself- all these have been colored by his loss, and they have been experienced and endured without him.
On earth I was nobody's son anymore. My mother soon took sick with Alzheimer's. It is a foul, lost feeling not being anyone's son, not belonging to anyone. We create relationships through out life, some are fostered and nurtured, some are lost and decay, but there is no bond like a father and son. There is only one.

Forget the Politics...Sorry....Doctor vs Provider what is difference between a psychiatrist and a psychologist??

2012-01-03T08:25:00.000-08:00

"Uhm same thing?" psychiatrist or psychologist? Nope. "Uhm ( from the sophisticated smarty pants of society) a psychiatrist can prescribe meds and a psychologist can't. True but is that the only difference, is that the defining divergence?"
As you probably know I am now from what I can see the most politically incorrect PRO-PHYSICIAN Blog I can find on the world wide web in the English Language. As you know I don't side step stuff by providing the same constant SAFE-helpful information on common medical problems that you can find in a thousand places on the Internet. Granted my blog is true honest and candid, it is highly opinionated, and I like to think I speak for a lot of doctors whom are simply terrified to say some of the things I say about the adversity a physician is up against in this day and age in the practice of medicine. Of course I don't provide SAFE blog posts on all the latest medical technology ipod and ipad apps and all that BS. Another good clean and SAFE fun topic for doctors to blog about.
So I have an opinion on this question and some facts. I even discuss it somewhat in When Can I Go Home?
Yes psychiatrists are physicians and they can prescribe medication,
But so can Clinical Nurse Specialists and Nurse Practitioners, and Physician Assistants, all have varying degrees of prescribing authority and autonomy and this varies by state. In a couple states psychologists can ever prescribe psychiatric meds.
The honest to God truth is that this physician extender, or mid-level practitioner model had its origins and motivations in necessity. No one wants to go into the Field of Psychiatry. There is a shortage of psychiatrists.

(I did a recent interview for the Minnesota Medical Associations monthly journal talking about the recession and the effect on depression. The sophisticated and educated Free-Lance Writer hired by the Association to conduct interviews had no idea that psychiatrists were just about the lowest paid specialty in Medicine.)

Okay so we know people don't go into psychiatry to make money and if they think they are , then they are misguided and ignorant, no big issue there.

I won't get into all the reasons why there is a shortage of psychiatrists, it isn't about the money, it is a host of reasons.

Now when you take the shortage issue and you couple it with that fact that politically and perceptually doctors are arrogant SOB's whom only care about making money and therefore just not good people, than you have the legitimization and flourishing of mid level prescribers in psychiatry.

Let me illustrate my point further by example.: I had a student nurse once, whom was getting a masters degree and essentially then getting her license to prescribe psychotropics, I was supposed to teach and train her. She was a good person and quite bright and caring toward patients. I asked her, "What is the difference between a physician and a nurse prescriber?" She advised spontaneously, " nurses are different than doctors. Nurses talk to their patients"
I will never forget that. To this day it irks me and hurts my feelings to no end. She truly believed that and was indoctrinated into believing that, She was not stupid just politically brainwashed.
All I do all day is talk to patients and give and give and give my energy all day. It has nothing to do with the biological mechanism of the meds. It is what a doctor- a good psychiatrist does, Nurses and psychologists do not have a monopoly on talking to patients.

So once I was at a music shop and buying my son some guitar strings the quintessential music story pony-tail guy saw my credit card signature and he said "Ahhh... MD making decisions" he actually had it right. No one has ever signed anything since the day I graduated form medical school below my signature, An MD always gets to sign at the most bottom line, I swear to God. The signature underneath everyone Else's assures that individual is the master of all liability and assumes all responsibility when the rubber hits the road,

Now the reason I talk about liability and responsibility goes to making decisions. By the nature of training the physician is really not allowed to have a comfort zone for making decisions, Decisions imply ultimate responsibility and liability. Sure you can have colleagues to consult get second opinions, but in the end the physician really has no where else to go. By the nature of the training doctors make life and death decisions in the middle of the night after no sleep for forty hours. That is pressure. Psychologists don't have that kind of training,
I may have blogged about this in the past but the point got driven home to me a couple weeks ago. Talking to some psychologists and one in training, this therapist trainee was overwhelmed and intimidated by a patient. She wanted to pass the patient off to someone more experienced, she did. no problem right? So how does that work. Will there always be someone more experienced and how did they get that way?
Training more Training and supervision.
Okay here's the bottom line as a psychologist in your training it is ethical and appropriate to give the patient away to someone Else if you are scared and over your head. No problem sounds like the right thing and it probably is, especially for the patient (psychologists call em' clients like lawyers and accountants and advertising executives have 'clients') I don't want someone who does not know what they are doing.

Now jump back 20 years, I'm in my residency I am overwhelmed and intimidated by a patient, I don't even want to see the patient behind a closed door. "Please someone more experienced take this patient off my hands. PLEASE! I'm just a resident,.... a doctor in residency training.
So an old supervisor long dead now says to me, you will have lots of patients over the years who are overwhelming, frightening, you have to learn to work through it, accept it deal with it, get good at treating them. There may be no one in the end more competent to fall back on. Get supervision guidance. Learn. I did, the patient lived and got through the year and things went okay, I did all right, and actually helped the patient. I did not have the luxury to dump the patient on someone more experienced.
Therein lies one of the most fundamental difference between psychiatrists and psychologists and nurses.
If a doctor does not know what they are doing, they damn well better get some supervision and figure it out, they don't get to send the patient somewhere else because "ohh it's too hard"

Anyway I hope and pray for all of you blog readers caregivers around the world that you had a Blessed Christmas or Happy Hanukkah and have a wonderful and prosperous New Year. And thanks for Reading my blog in 2011. I know most people are looking for the difference between delirium and dementia and depression, or questions about Alzheimer's being a mental illness. I will keep blogging in 2012.
I do not forget all of you caregivers world-wide, and we will hope and pray for some SIGNIFICANT Alzheimer's progress in 2012.

Hello Old Friend

2011-12-24T10:06:00.000-08:00

Since you are a world renowned author and authoring another book, I thikn. I ike to take this time and say it was nice to know you when you were just a lowly shrink. Best of Luck my old frined in all you do.

God Bless,
Joe

Physician Coders, Pearl Harbor Annniversary and other issue

2011-12-07T10:49:00.000-08:00

Well I passed my Billing and Coding Exam for the AAPC, the American Association of Professional Coders. That is sort of the world that gets physicians and facilities sometimes paid. Every bill to a third party provider that is Medicare of a Private Insurance Company has to have a Diagnostic Code and a Procedural Code. There are thousands and thousands of codes, with several digits. For example the diagnostic code for PTSD is 309.81. In the billing and coding world if you don't bill the right and correct code and have the proper documentation it is a reason and an excuse for an insurance company to not pay the doctor or a facility, or at least delay payment. It is not like medicare or insurance companies have money sitting around and just can't wait to pay doctors. When you can delay payment or simply not pay a doctor and hope that no one notices, that money sits somewhere, typically it is gaining a bit of interest. So to delay payment or not pay is cost effective for the insurance company no matter whom it is. Most people that work in billing and coding do not understand this part. Moreover most people think doctors get paid lots of money anyway, way too much and this makes people angry, this attitude actually provides support to a system designed not to pay doctors if they don't have to. Most people are oblivious too it.
Now there are tens of thousands of people that work in billing and coding. Keep in mind they have families they have to support and feed. The money to pay them comes from somewhere. It is considered a health care cost.
I took the certification exam because I wanted to understand this world. Most doctors coming out of residency and medical school don't even know a thing about billing or coding. We rely on others to do it for us. Of course without physicians there would be no billing or coding jobs. There are only a handful of physicians in the country that are certified coders. I suspect some or most of them are good business people. I know nothing about business.
Billing and Procedural Codes have nothing to do with the practice of Medicine, most coders don't believe that. The exam was 5.5 hours long. I had to go to the bathroom during the test, but could not allow myself the time, since the clock does not stop. To pass the test and become certified you need a 70%. I was sure I flunked. Lots of people flunk. I got a 90%. I was happily surprised. I am turning fifty in one day and I worry that I am not as cognitively sharp as when I was 20 years old. However this test that lots of people flunk reassured me a bit- that I still got it.
The test is hard and chaotic like the world of billing and coding. You actually sort of have to think more like an attorney than a doctor. Find those hairline splits of the black and white dogma and make an interpretation. Remember lots of lawyers wanted to be doctors, but very few lawyers "settled" for medical school. Medical School is harder. The coding certification test was really hard. Maybe as hard as a test in medical school.
I take care of patients all day, every day. regardless of how I feel or how I am doing. I get to give 110% every day to patient care. Call it a responsibility, a burden or a privilege, it is what it is and I probably won't quit my day job anytime soon to be a coder. If many people and entities have their way, we can maybe drive most doctors out of the practice of medicine and make it so arduous to practice medicine that no one wants to go to medical school. Then nurses, technicians and computers can practice medicine, the masses of people will be so dumbed-down by society, that they maybe won't know the difference. Some think this will save money. It won't. I dont' know if this will happen in my lifetime, but I am happy to be a bit more versatile with a certification in coding, should physicians practicing medicine become obsolete. I may have a marketable skill.+++

Now take a moment to remember in your hearts and in your prayers those Veterans of Pearl Harbor and WWII. It happened seventy years ago today. The last great generation, the last War the United States flat out won. I've visited Pearl Harbor and I've been to Hiroshima. Both are incredibly moving places. There are not so many WWII veterans living anymore, they would be in their 90's, many of them. Thank God for them, because there is a good chance that I would not be writing this blog and you would not be reading it, if it was not for them.

PTSD, and Alzheimer's Treatments- FDA-on-label or off label, formularies, studies

2011-11-18T13:53:00.000-08:00

So what is new with the treatment of Post Traumatic Stress Disorder? Well we still have two government approved meds, one is Paxil (paroxitine) and one is Zoloft (sertraline). It has been over ten years since these were approved and have been indicated by the FDA for the treatment of PTSD. Sometimes they help and sometimes they make things worse. Basically most psychiatric meds out there have been used for somebody somewhere to treat PTSD.
A few basic facts:
Most people associate PTSD with veterans of combat wars. The truth of the matter is in shear numbers there are more civilians with PTSD than veterans. However for those military veterans whom have served in combat there is a much higher percentage of that sub population with PTSD than in the general population. Combat increases the possibility of developing PTSD. Not everyone whom has serves in combat gets PTSD. The reason there are a larger number of civilians with PTSD is that there are simply more civilians than those whom have served in the Military, by shear numbers.

The percentage of women with PTSD is higher than men 10% versus 5%. Most traumas being physical and sexual abuse and violence and the same for men as well as combat. Motor vehicle and work accidents are also not unusual sources for the trauma.

Most people that have experienced a psychological trauma (an event involving death or serious injury witnessed and involving certain responses like helplessness and terror) do not develop chronic long term PTSD. However about 30% of people do develop it. (Millions of people).

As far as treatments, remember the FDA does not do drug testing, they simply review what comes across their transom, IE mostly studies submitted by the industry (pharmaceutical). PTSD like Alzheimer's disease, is really hard to treat and no one med emerges as the gold standard. Therefore drug companies don't want to touch it. It is more lucrative to simply refine and develop another med in say an illness that does already respond well to medications, like good old major depression.
It is hard to get a med that sort of works for some people, some of the time and spend billions on it only to have the FDA say "no-go drug company, it does not work well enough consistently". . The drug companies like to stick with things that they know will work, and the studies will show really good results so that the government will approve it. The FDA does not say "Hey get more meds for PTSD and Alzheimer's", that is not in their cubicle or jurisdiction to do so, even though we all know we need to develop more and better meds to treat these two catastrophic illnesses.

We have lots of meds used "off-label". Example a patient with PTSD has tried paxil and zoloft and they get worse of they get side effects and can't tolerate the med, you can't really send that patient away for years, till we have a new FDA approved med we can offer. In other words there are lots of studies and data indicating efficacy and positive results on a certain med for say PTSD.
Researchers like to get published, they like to refute each other, They like to get a name and get famous. Sometimes the drug company funds a study and shows great results and then others say it does not count because the drug company did the study and therefore the way the study was set up was not good science-- since the study was designed to show the med worked.

Sometimes studies are set up with the hopes of showing a med does not work:

Why would that be? Well if a med is really expensive and a doctor knows it works for certain patients but say he or she works within a health system that has its own pharmacy formulary that only covers certain meds, then it may be too expensive to tpay for that med. So it is not listed on the formulary. Therefore that doctor won't be able to get that med within that health system for that patient.
Now if you can get a big name, big time, researcher to set up a scientific study to show maybe that type of med is not effective, even though the doctor may have been using that med or combination of meds for years to help patients. Now the doctor can't get it because he wont' be going with the most recent studies and evidence.
It would make the doc look bad if he went against that most recent, vogue, trendy scientific study.
End result is doctor is not allowed to prescribe the med they know is best for their patient.
Remember formularies are negotiated between health care systems and insurance companies and have nothing to do with if a medicine being helpful or not. It is basically economical and not clinical. But if you can get a good study from a big name researcher behind it -to dispute a meds clinical efficacy, it just happens to be 'cooincidently' economically desirable and sweet for the health care system. The slug doctor and the poor patient are caught in their middle and not heard.
Remember also if a doctor is prescribing something "off label" that is for something not indicated by the government, even if they are trying to help their patient and there is a bad outcome, in some jurisdicitons, that doctor is liable and a bad doctor.Yet if the doctor knows there is an 'off-label" treatment that works well in may patients and they withhold it from the patient because the drug company did not push it through the government to get an indication, then it may be unethical for the doctor to withhold that "off-label" treatment if they know it has the potential to provide benefit.

Conversely when a med comes out on the market, that has gotten approval from the FDA for some indication or another, and even been advertised on TV, the doctor may know in certain patients or most patients that it does not work as well as the studies and the TV commericals show based on real life clinical experience then what does the doctor do? Direct to consumer advertising makes patient ask for meds by name. It builds instant credibility. If the governement approved it, and the doctor does not pracitce exactly what the govenremnt says, and what the TV commercials say, should you get a new doctor?

Does the Pain of Alzheimer's Ever go Away?

2011-10-23T16:40:00.000-07:00

It has been over thirty years since my mother was diagnosed with Alzheimer's. It has been 24 years since she died of the disease. I was seventeen when she was diagnosed, my book talks all about that struggle. But something is happening now around me now and it is very strange and very sad. It stirs a myriad of emotions for me. I was a junior in high school when my mother was diagnosed. There was no Internet, no Alzheimer's Association, no blogs, no Aricept, generally no awareness and no hoopla. We had "hardening of the arteries" and old people were "senile". That was about it. For awhile I had to sort of cover up to my friends, my mother acted weird, sort of crazy. It was most embarrassing and humiliating. It made me really enraged. Now some thirty years later I am getting phone calls from many old friend whom are now going through what I went through when I was 17. All the signs and symptoms of dementia. Nursing homes, sibling power plays. Meds, Aricept, Excelon, somehow now I am the expert having lived through all this so many years ago.
They turn to me for advice. Sadly I don't have the answers in the end. I can tell them all about the meds, all about my experience, but in the end for most of the dilemmas, there is no right answer. Should my mother go into a nursing home? She she keep living at home? Is it safe. What is the difference between dementia and Alzheimer's? For some questions I have very clear and informed answers.
With other dilemmas like the nursing home question I advise there is no correct or perfect answer, you have to try to do the best you can, of course you want to stay in the home as long as you can, but when is it not safe, who decides? Basically you do the best you can and no matter what it is going to hurt and it is going to hurt am lot.
Two old friend from high school and college had parents die this year, once again in a perverse way I am the expert. Having gone through it when I was a kid, all I can do is listen. It was impossible for many friends to conceive how bad it felt for my father to die in high school or my mother to get Alzheimer's disease.
I wish people could have related to me then, they couldn't.
Now so many years later,, I am hit with a wave of sadness and anguish for them, I know it hurts for them at 50 years old as much as it did for me at 17 years old. I am filled with sorrow and a deep compassion for them, I want to fix it but I can't. I listen and tell them that is how I was feeling back in high school, so long ago, it is a strange and surreal experience.
Do I feel indignant because none of these friends could really understand me back then like I understand them now? Not really, just a real deep sadness for them. They will go on, but it is never the same, loosing a parent to AD is as bad at 15 as it is at 50 or 70, it is always bad.
Then we can talk about the resilience of the human spirit. Makes us feel better. I like to refer to it as a survival instinct and that's about it. I am convinced that had my father not died when I was sixteen or my mother gotten Alzheimer's disease, I would have been a hell of a lot stronger as an adult and would have had a much easier time of it. And no I am not talking about getting through medical school and all the hateful stereotypical prejudices people have against doctors, I am talking about life. So call it resilience or survival instinct,. Nietzsche was wrong when he said "what does not kill me makes me stronger", that is total BS. It greats on you and tears at your psychological and spiritual core, we are human beings not robots.
Alzheimer's is isolating and it always hurts, regardless of how long you have lived or how strong you think you are. I tell My Friends I know how they fell, I am so sorry, and I know they will get through it. I relate to their every scenario, every painful situation, and regardless of all the hoopla around Alzheimer's in 2011, the pain of what it is like for my old friends to now live with an Alzheimer's parent has not changed at all in thirty years, it is the same stuff, the same pain, I went through as a kid. It hurts them now as it hurt me then.I am sorry I had to go through it and I am so sorry people still have to go through it., but you will make it..

Would you recognize the early signs of Alzheimer's? - Healthy Living on Shine

2011-10-11T15:17:00.000-07:00

Would you recognize the early signs of Alzheimer's? - Healthy Living on Shine:

'via Blog this'

am only posting this so you read the comments. I want you to see what folks really think about us. remember you heard alot of this from me, i think.

God Bless,

joe

Duluth, Minnesota Alzheimer's Walk

2011-10-10T21:31:00.000-07:00

Its that time of year again. Annual Alzheimer's Walks to raise money to benefit the Alzheimer's Association, and happening all over the country. Here are a few pictures from the one in Duluth, Minnesota at Spirit Mountain. As you can see it was a beautiful fall day, last Saturday Morning. Lots of people, including myself turned out. Congratulations to the Local Alzheimer's Association in Northern Minnesota Region for a successful and well attended event.

Really: What is New In Alzheimer's Research?? Diagnosing AD

2011-09-24T23:57:00.000-07:00

Well here we are in late 2011. One of the things that is astounding to me is the disconnect between the research experts and those in the daily grind. If you are the caretaker of a loved one or live with someone with AD you are the real expert in my opinion.
So we have no cure, we have no definitive way to treat it and we have no definitive way to diagnose it with 100% certainty except brain biopsy or autopsy of brain. I need to re notify and present those grave and awful facts to give an understanding and perspective of where things are at and break it down for the general public, so we can understand exactly where the current efforts to combat the disease are at. I suppose a lot of websites and organizations try to do that, but it is not always easy to follow what the heck is going on with AD.
The hottest research, at least what is put out to the media outlets, and available to you and me is in diagnosis. In terms of treatment or cure, one of the things you have to understand is that a lot of the medicines and treatments and funding for studies comes from the private sector IE. big old pharmaceutical companies. I think you know as well as I do that drug companies are considered sinister, evil and only concerned about the bottom line. Everyone likes there funding though. But with the Obamacare crisis- the acceptance and positive regard for drug companies is probably at an all time low. That actually hurts research efforts for things like Alzheimer's disease. -(swear to God)
In Duluth, MN- a city and state that arguably, collectively loves to hate physicians as much as any place: I can barely even talk to drug reps anymore. I almost don't let them in my office. If a doctor around these parts does interact with a drug company representative, then his or her name may be smeared all over the local fish wrapper newspaper for being bad as a doctor and moreover as a human being and everyone believes it.
Who is going to pay for the research. Just dont' hear much about the plight of AD with the health care antics, do you?
So take it up with the publicly funded agencies like the NIMH and the NIH. Very politically correct since they are "PUBLIC". Publicly funded research is up there with the perceived unconditional altruism of the "non-profit" tax status entity. Whatever way you look at it, they are all politically correct right?
I am not going to even get into the funding for AD research relative to many other diseases, but lets just say by looking at the numbers, we can draw an easy conclusion that AD research may be underfunded in the public sector.
So the thought leaders: those in the Research trenches while liasoning up with the Alzheimer's Association, want to figure out a better way to diagnose AD other than a brain autopsy. We want to diagnose it early. Really really EARLY. Early diagnosis without question is good-clinically and humanely it is ALWAYS good. I will not consider the economic, bio-ethical and therefore political implications- the liberal weasels will talk care of that, and it won't be pretty for those whom care about the sanctity of human life- like myself and perhaps most readers of this blog.
Now let's think about the AD process. It is a two-fold process: internal and external.
There is something internally going on at the brain cellular level and also something externally going on with the victim- the behavior, the memory, the personality changes-you caregivers are the experts on the external manifestations of the disease. You live it everyday.
Now consider this-A person does not wake up one day and have Alzheimer's. We all know this and it is established that there are changes at the brain cellular level and gross physical biological changes to the brain. Amyloid and such- the battle cries and buzzwords we have all heard before. plaques and tangles amyloid and tau
It should not be a leap of faith to say that the internal changes to the brain start before the external changes. That's just how the brain and the disease works. Remember we have millions and millions of brain cells, and if you kill one cell nobody is going to notice too much. The disease has to destroy a lot of brain cells to notice externally, that can take years.
Researchers want to make the diagnosis early in the process, really early. Once again, what is happening internally to the brain and the cellular level in an AD victim may start years and years MAYBE even decades before the external change start when victim starts showing the signs of Alzheimer's all of you are so familiar with. If you get it early there might be something more we can do about it. Maybe some day at least stop it before it advances.This is a good thing. It is why we want to find it early, before the external manifestations start.
Now how do you do that. Basically we can look at pictures of the brain, through neuroimaging, CT MRI, PET SPECT all kinds of elaborate scans. We can tag certain cells to go to certain parts of the brain that might be showing changes in Amyloid composition per say. not new to medicine but in terms of radioactively tagging cells to look at the brain, it is not as common and established as say a scan of the heart using tagged cells.
So there is a big area-Advancing Neuroimaging, sophisticated picture of the live human brain and its real time functioning. in PET scans, one of the really expensive but promising radio tracers is called (PiB) which is short for:
Pittsburgh Compound B This can help trace and assess Neocortical amyloid Burden or how much amyloid is accumulating in the brain, with pretty good accuracy.
The second diagnostic tool we have is laboratory tests either blood or cerebrospinal fluid. Biomakers Biomakers and Biomarkers. BIOMARKERS.
So that's it. We have blood (and spinal fluid) and neuroimaigng to work with, and that's about it. Not too much else these days. Those are the main things we have to work with in terms of diagnosing that disease when it is still internal and otherwise invisible, years before it externally manifests itself. Yes of course we have genes to look at and work with, but we have been barking up that tree for a few decades now, and it really isn't totally panning out for everybody across the board as a gold standard to definitively make the diagnosis or rule it out in anyone and everyone. So take some of those better studied genetic markers like ApoE, (well discussed everywhere now) and lets clump them into blood work studies.
Now is there a way we can combine all the bloodwork and biomarkers and Amyloid Burden in the Brain by imaging? Is there???
Well it just so happens that the AIBL (Australian Imaging, Biomarkers and Lifestyle Study) is working on doing just that.
Basically they took 273 people , performed the expensive PiB-PET scans and then also took bloodwork from them. Studying the blood they used 9 different biomarkers in a panel, thing like cortisol and ApoE were tested in the blood panel. They figured out the biomarkers that would correlate with the different amounts of amyloid burden in the brain that would predict and be consistent with developing AD. Basically not an easy thing to do.
Then they took another 817 people or so and didn't do a scan. They clumped these people into clinical diagnosis: AD (external Alzheimer's); MCI (mild cognitive impairment); healthy individuals.
!00% of the Alzheimer's victims had a high neocortical burden based on the blood panel with the 9 biomarkers, (remember the panel correlated with the neuroimaging originally that showed the brain amyloid.
Okay so what does it all mean?
Basically it is moving us a little closed to developing a blood test to allow us to diagnose AD much earlier before it externally manifests. No we are not there yet.
The idea is neuroimaigng is too expensive, getting a spinal tap is too invasive , and we need a good blood test that will work for everyone to make the diagnosis before the disease outwardly manifests.
Remember all the research is happening around the world not only America. As I said in previous posts, it is collaborative and competitive. Everyone wants to be the first to make that discovery. No one openly admits it. That just would not be altruistic. '
So that's where the efforts are. If we can get it diagnosed early, have a mainstream blood test that you can get at the primary care clinic, then perhaps we can find more effective treatments earlier on inn the disease process. . If we don't have meaningful treatments, but we can diagnosis it really years earlier... well the way American society it acting, We will be in really big trouble.

PHYSICIAN BURNOUT!

2011-09-19T10:46:00.000-07:00

Wow, what is it? Last I checked physicians were not allowed to "burnout". Burnout is even somewhat poorly defined, since it is not a clinical concept. Everybody knows what it is but it looks different in different people. Consider it a chronic state of emotional, physician, intellectual and spiritual exhaustion-In this case induced by ones job, or occupation or in this sense I still use the term profession. It can manifest with more cynicism, physical health problems, addictions, calling into work sick-(doctors don't get to), anger, irritability, slowed cognition, anxiety, marital and relationship problems and of course the catch all term "depression". Sometimes the depression is a clinical depression.
People end up hating their work, retiring early (if they can) switching careers( if they can) and a whole host of other consequences.
The fact of the matter is just a few years ago, almost all physicians wanted their son(s) or daughter(s) to become doctors. Now only some 30% encourage their children to go into medicine. Most docs over fifty years of age want out ASAP.
There are lots of little initiatives to help physician burnout, often run by para-professionals, psychologists, nurses, you know people that didn't go to medical school, didn't give up all of their adolescence and most of their adult lives to serve. Interestingly enough many of the physicians who lecture about physician burnout have gotten out of the game, they have gotten out of direct patient care.
Now I will tell you the rest of the story, that no one seems to comprehend, even most physicians, the anti-physician New York Times media type outlets, and the general anti-physician mainstream society.
Most.....no make that ALL doctors who make it (WHO MAKE IT) IE gotten through school, residency etc. want to serve others, they want to help patients. They are also as a whole very self-punitive, very even shame based, we are our own harshest critics. Most take it very very hard and suffer in silence when things do not go well with a patient. Moreover we are not allowed to whiners, it is politically incorrect, and just plain wrong if you are a physician, this blog is just plain wrong- because it talks about the things the smiley faces whom have gotten out of the clinical world and make a decent living, as well as all the physician despisers annoyed- it is uncomfortable to think about.
Most docs are perfectionist by nature, everyone whom isn't this is WEEDED OUT in the 12 year process. The integrity and commitment is phenomenal, and yet their is something profoundly masochistic and self-punitive about the culture and very nature of the indoctrination of becoming a physician. In other words you pretty much give up yourself, it is selfless. That is in the backbone of any good physicians, and most are good. The not so good one 'wannabes', did not have the intellectual or spiritual or emotional commitment.

So here is a secret, maybe not a secret but a taboo statement within society.- a lot of physicians want out of direct patient care, this is where the stress and burnout comes from. Why? There is more pressure than ever, to see patients- as many as possible, that pressure comes from payers, administrators etc.
There is literally a bulls eye on physicians backs in regard to litigation, when we don't get the outcome we want we immediately want to sue the doctor. We want retribution, accountability. We want our doctor to be perfect, to know everything and have a wonderful bedside manner.
But nowadays we live in such a physician-hostile climate, we are ready to sue if something does not go our way. It is another pressure. Also we really place no actual value on the doctor. We know how much it costs to get our oil changed in our car or to get a crown on our tooth at the dentist, but we never really know how much a doctor's appointment costs. Moreover we get huge uncovered bills from institutions and the general assumption is that all that money is going into the doctors pocket. I will never be able to convince anyone outside of medicine that the doctor does not see that money. It helps us devalue and hate the physician even more.
And here is another concept- there is generally a breakdown of the family more social media, less human contact and intimacy and perhaps as a society we treat each other with less respect than ever. Call it a post-war pervasive narcissism except know we are about 5 generations post war, and have been busy indulging ourselves for decades, feeling good putting ourselves first, convincing ourselves that the destruction of the nuclear family is cool and politically correct. what does this have to do with physician burnout???
NO ONE WANTS TO PAY TO BE CARED ABOUT. The physicians office is one of the few institutional bastions left in our ever-advancing society where a person is supposed to and can feel cared about.
With that said a person can never feel cared about from the nurture they didn't get from their fragmented family of origin. Now couple that with a doctor whom you don't pay- (insurance does or does it?) and that doctor is working hard to be good enough and help you as much as they can, but it will never quite be enough given the combination of factors conscious and unconscious between patient and doctor. It is a perfect storm for an -anti-physician society to advance their distaste towards doctors and an even more perfect storm for physicians whom actually take care of patients all day, to become really really burned out.
But since we are so shame-based, it is completely taboo to say we dont' like treating patients anymore. That is a sign of being bad, and that is the LAST thing a doc wants. So we burnout or quietly switch careers, except most docs have no marketable skills outside of medicine.
Physician burnout is more complex than eating right, balancing work and play, getting enough sleep, prioritizing family, exercising. Yes all that stuff is crucial to avoid burnout but it really needs to be understood, from a developmental and personality-character perspective to be able to do something more about it. One must also consider what has happened to society in the last four generations, to understand why there is more physician burnout.
I would love to see a doctor that still takes care of tons of patients all day speaking on burnout, except they don't have the luxury. Sorry I'm just whining, I must stop. I know like all good docs all over this great nation of ours, I will just keep trying harder every time.

WAM Match Appeal #1: Advocates 9-2-11

2011-09-06T17:09:00.000-07:00

WAM Match Appeal #1: Advocates 9-2-11:

'via Blog this'

caring for those with Dementia.

God Bless,

joe

Eternal Peace or endorphin release, or God, religion, afterlife, the divine

2011-09-06T12:47:00.000-07:00

Well it has been a really long time since I blogged. The summer is officially gone by us as we just finished labor day. It is coming up on two years sincee I fell off a scooter and broke my face in 4-5 places. I have ringing in my ear and a tumor called an acoustic neuroma, which Mayo clinic can do nothing about except watch it and charge me lots of money that my insurance won't totally cover to pay for staging it once a year. It is on my cochlea which is sort of the end of the eight cranial nerve the other end connects up to your brain.
Also loosing my hearing in that ear. Because of location that won't operate. More later on this.
Not too much new on the AD front. Australian study and Mayo looking at a bunch of blood markers, a whole panel of tests to try and identify Alzheimer's in people before it becomes clinically apparent and obvious. So earlier recognition is where it is at. Testing and findingg it before it becomes apparent, maybe years before. No clear treatments emerging.
So this summer I went to a Benedictine Monastery for a few days in St. Leo Florida mostly to pray for healing for my ear. I ended up praying for my enemies and people I can't stand. My ear did not get cured but me stress level went down considerably.
I also ran my first 5k marathon this summer, ironically with the exception of the cancer in my ear, I am in probably the best shape of my life at nearly 50 years old.
I had a bit of a spiritual moment. I was with my son and a climbing friend. We climbed the South Sister in the Cascades in Central Oregon. The summit is about 10,500 feet or so. We started at 5AM and completed the summit about 12 noon. Note that this is a climb I never completed in 1994 when I was 33 years old. I started out to late in the day on that one. Now at almost 50 I completed the climb.
On the way down we rested a few times. At one point, I sat down then layed back. The sun shined on my face and warmed me on the side of the mountain. I said aloud, "this is what it must feel like to be dead." I didn't mean it in a bad way, but it upset the friend my son and I were climbing with. He said, "don't talk like that." What I meant what I felt so incredibly at peace, I wished for nothing, felt no stress or worry, just the beautiful sunshine warming me. It was so incredibly comfortable. I corrected my self and said, "No I mean this is what heaven must be like." I felt really peaceful and loved and even connected to God. Nothing hurt, I can't remember my ear ringing or throbbing, just peace.
This happened a couplee weeks before I went to the monastery.
It is unusual to have an experience like this. One could say I was exhausted from climbing for 8 hours and it was cold and brutal winds at the top of the mountain but on the way down it was sunny and nice. Perhaps it was endogenous opioid release, a similar feeling a person may get from taking opiates.
On the other hand it simply could have been God and a peaceful loving content and fulfilled feeling.
You see how I struggle between the science and the spiritual.
At any rate I was lucky to have this moment, this time where I felt close to God.

SOUTH SISTER in OREGON

After loosing my parents at an early age, a lot of life has been filled with a certain stress, sometimes an anguish, (read the book) like everyone I have my struggles. As a doctor and a psychiatrist, a lot of my life is surrounded by the worst pain and evilness known to mankind and the terrible things that human do to one another and how it affects them. So if I get a moment on the side of a volcano and it is complete with human fulfillment I have to take it as a sign from God. I wish I had more of those signs, but we take what we are given. It was a good thing, perhaps a divine thing.

Thanks to Normal, Illinois for Book Signing

2011-06-29T16:12:00.000-07:00

Lots of thanks to the very kind people of Normal, Illinois for coming out to the book signing at the Library last week. Here are a couple of pics from that signing.

New Blog: Medical Fiction Writer and other updates

2011-06-14T20:22:00.000-07:00

Good Day. Long time no blog. I have been busy with some Health Care Issues lately. In fact I have been down to Mayo Clinic twice since I last blogged. (Great Venipuncturists at Mayo, also fairly decent restaurants in Rochester, MN) I won't bore you with the details right now, needless to say it sucks, but then you go on as best you can, as time keeps marching on.

Also I have been busy trying to survive as a Private Practice Physician in the State of Minnesota, despite the best efforts of many bureaucracies and agencies to annihilate entities like myself: all done of course shouting the Battle Cry and in the name of health care "REFORM". When it is all said and done, we will still need doctors to take care of patients and patients who need to be cared for and cared about by their doctors.
It is absolutely astounding how many people are now employed (with really good employee health benefits I might add) to hinder, hamper, occlude and basically prevent physicians from simply spending their time taking care of their patients. ASTOUNDING

On the lighter and more fun side of things, I started a new blog.
It is called MEDICAL FICTION WRITER CHECK IT OUT. Not too much there yet, but it will get there. Over the last couple if years I wrote another book. very different than When Can I Go Home?. This one is a work of - you guessed it-medical fiction. It is sort of a drama, action, crime, romance, with chaos, violence, doctors, lawyers, courtrooms, lots of things. Stay tuned. I'm in the process, a very grueling process of doing the first edit.
The blog will be for writers and readers and about writers and readers of medical fiction. and of course Medical Fiction Books.

For all you Alzheimer's caregivers, it is Summer at least in the Northern Hemisphere, if that's where you are. Try to get outside for some warmth, even for a little while. Keep the faith, do your best, I know you didn't sign on for this, but I am sending you my positive thoughts, hopes and wishes and energy right now. What I still have of that positive energy, it is there just below the surface of my cynicism! I promise though, that positive energy and hope is real in me, just as it is in you, whether you know it or not. So don't get too lost in losing the daily battles, overall by caring for your loved one, with your devotion and dedication, you are winning the war on this thing.
God Bless.

Brand NEW BOOK SIGNING and Alzheimer's Q & A suburban Chicago and the Heartland

2011-05-15T12:09:00.000-07:00

Monday June 20, 2011 - 7 PM Evanston Public Library, Evanston, Illinois

Thursday June 23, 2011- 5:30 PM Normal Public Library, Normal, Illinois

CLICK HERE FOR MORE INFORMATION

Happy Mother's Day

2011-05-07T08:55:00.000-07:00

Happy Mothers day, and for all of those with dead mothers, those who have lived though so many of these mother's days without the support, the basic self-esteem and innate confidence that come from having a mother on this earth, you are not alone. God Bless and carry her strength and love with you.

Oh and if you are fortunate enough to have a Mother on this Earth, don't forget to honor her the rest of the year, not just Mother's Day with brunch and flowers,

Nocebo Effect-Blog Post From FreeLance MD

2011-05-06T08:25:00.000-07:00

Here is a post I did for Freelance md it is on the Nocebo effect. Another Website Called Physician Nexus added it to their site. I was invited to post and told I could post on anything I wanted, related to medicine or doctorhood. Well that covers about a billion potential topics. I wanted to cover something out of the mainstream, that you won't see many people write or talk about, for a whole host of reasons. If you have any questions, please feel free to ask or comment.

NEW PODCAST- Delirium vs Dementia vs Delusion Some Considerations

2011-04-23T15:19:00.000-07:00

Click below on play bar to listen

Podcast Powered By Podbean

Here is a new podcast on Delirium, Dementia and Delusion. Some of the major differences and considerations. If you have quesitons please email me or comment below. The podcast is in lecture format, and there is too much to cover for one podcast, but some major features and genreal informaiton are discussed. These issues seem to come up frequently on the blog in search engine queries, so I hope this podcast is helpful.

Book Giveaway Winner Goodreads,and New Zealand stuff- love the Kiwis

2011-04-16T14:10:00.000-07:00

Congratulations to Stan down there, over in Christchurch, New Zealand. He is the winner of the When Can I Go Home? Goodreads book giveaway. He will receive a signed copy of the book.
I have got to say I love and always will have a fondness in my heart for New Zealand. Long ago when I was a young man like age 32, in the early 90's, I worked a locum tenans psychiatry job in old Palmerston North, New Zealand. working at Wanganui-Manawatu Health later named Mid-Central Health. I was fresh out of residency and life was hopeful. It seemed optimistic that you could actually pay off your loans and get out of debt as a practicing psychiatrist. -Ha!. It seemed like being a physician was a respectable thing to do in society (I hadn't lived in MN yet hah ha.) and all around life was okay. The world seemed my oyster. So I explored the world including N Zed.
Working and paying taxes there was interesting. The things that I remember most about the work are the fact that the Kiwis never seemed to wear shoes in the summer. I was there in Dec and Jan, the middle of summer. In terms of psychiatry the thing that I will never forget is that NZ was a much less violent society. It came out all the time in the daily practice of psychiatry. The Kiwi's were not always interested in getting ahead of one another, of messing one another up of dominating one another, of killing one another. It affected a person's mental health. It was a cultural phenomenon. They were less violent. It was also nice not to take you life into you hands every day as many American psychiatrists have to. They were polite too. "Please" and "thank-you" were rampant.
I remember the boiling ground and Geo-thermic activity in Rotorua, Jet Boating, Climing Mt Taranaki or Eggmont, whichever you prefer; Repelling into a cave at Waitomo and wathcing glowworms on the ceiling; hitch hiking from Nelson on Christmas Day to get to Picton, to catch the Ferry across the Cook Straight to get back to work, and of course bungi jumping at Lake Taupo (I enclosed an old pic)
Driving on the left, eating pies for lunch, meat pies (before I had to worry about cholesterol)
Hanging out and exploring and doing many of these adventure with my buddy Darren, who worked as a psych tech.

Sad to say I only spent a few hours in the city of Christchurch on the South Island, where Stan lives. Remember that's where the earthquake was, It seems in the United States if something is not blasted in our face by the media we quickly forget. It was only a couple months and 181 people died there. So remember them and their families in you hearts and prayers. Now is the hard part for grieving. Remember all the "disaster mental health experts" have pulled out, because there is now little chance of getting their mug on the TV and flaunting their expertise. The sad things is this is when the going gets the toughest, after a disater when the media and experts have pulled out.

Anyways NZ rocks!

Simpler Times Lake Taupo Bungi Jumping

Is There A Dr. In The House?

2011-04-05T16:37:00.000-07:00

NO there is not. See Doc is playing in the sunshine in California. Long Beach, CA that is. I drove up from Oceanside about 80 miles south to see the bugger. You know he is all sunburned and man his wife must not feed him. A good wind could take him away. Just being a pain Doc. He is well and it was great to see him. This is his nutty friend with Alzheimer's, just letting you know that today he is fine.

God Bless & Keep You &This Country of Ours!!!!
joe
Living With Alzheimers

BOOK SIGNING IN LONG BEACH: ALZHEIMER'S DISCUSSION and Q&A

2011-03-18T11:19:00.000-07:00

I will be in Long Beach, California on Tuesday April 5th for two separate Alzheimer's Discussions and Book Signings for When Can I Go Home? I am pleased to say that the signings will be held at Two Neighborhood Branch Libraries of the very fine and extensive Long Beach Public Library System.

First is Alamitos Neighborhood Library April 5th from 12-1 PM.

Later that Day at Los Altos Neighborhood Library April 5th from 4-5 PM.

Both Events are Free and open to the Public.

Don't Forget April 10-16 is National Library Week

My mother died of Alzheimer's disease.......

2011-03-06T14:16:00.000-08:00

Wow, it has been two months since I posted on this blog. Not much new in the Alzheimer's world as far as cures or new effective treatments. Of course the National Alzheimer's project passed, if you are suffering with AD or are a caregiver, this really does not change much in your life on a day to day basis. Perhaps our children or our children's children will not have to be stricken with AD.

24 years ago today, March 6, 1987, my mother died from Alzheimer's disease. Her children were at her bedside as she took her last breath. It was five days before her seventieth birthday. I was 25 years old and a third year medical student. She had been diagnosed 9 years before she died and went through all the classic stages of AD. By the time she died it had been so long, since I had known her as my mother, since she was able to converse, laugh, smile, at times it was hard to remember her that way.

About 10 minutes before she died, I was sitting at the foot of her bed. (We were all holding vigil, she was fairly comatose, No feeding tube, just nasal cannula oxygen. She had been like that for almost two weeks/ We all wanted her to stop suffering, we wanted it to be over. For her torment and suffering at the hands of this rotten nefarious neurologically deteriorating process.) In the final ten minutes of her physical life on earth, a wave of anguish came over me. I had a sense, some atavistic instinct that it was over. She was leaving the earth. I started to cry hard, and I felt so terrible, it seemed that all the years I had tried to be strong during her ordeal were coming out. I didn't want her to die, I wanted her to be back and be her old self. I knew somehow that it was over, the Alzheimer's had taken everything and the last thing left to take was her physical life, her breath.

The sad thing is, when you loose a parent to Alzheimer's, you feel like a part of yourself dies with them. That feeling never goes away. I think because it in part a living death every day. A slow progressive heartbreaking daily thing. On one hand you hope for a cure, and on another hand you want them to get better and die and stop suffering. It is a profoundly ambivalent form of grief. Then when they do physically die you are so damn heartbroken over the whole long drawn out process.
another year has clicked by. most of us always remember the date our parents died. I guess it is one more way to mark the life cycle.

To all those struggling, if you are having a bad day, hang in there, life is not static it is dynamic, it will not always feel as bad as today. If you are a caregiver and you loved one is having a good day, cherish it, laugh, smile, hold it in your heart forever. God Bless

Holding Hands

2011-01-31T07:27:00.000-08:00

Sometimes, photos speak for themselves. My daughter holding hands with my dad yesterday at his assisted living home:

Inside the Mind of the Shooter, Mental Illness, Murder,

2011-01-16T15:03:00.000-08:00

Well it is over a week since the Tuscon tragedy. I like you have watched all the events of the week unfold. The political manuevering over the week; the age old discussions and debates on mental illness are predicatable. I know this is an Alzhiemer's blog. My mother died from Alzheimer's disease 24 years ago. I took care of her, I wrote a book about it. I became a psychiatrist. I treat mental illness.
Lots of people want to know if Alzheimers is a mental illness. They want to know becouse there is much stigma associated with mental illness. People want to know what delusions are: so they come to this blog.
I get frustrated with the lack of information on mental health and insanity and dangerousness that has been presented in the media this past week following the Arizona tragedy.
I have treated tens of thousands of patients with mental illness over the last 19 years.for various reaons  people dislike psychiatrists and are dissuaded from even begining to understand the plight of the mentlly ill in society. People are afraid of those with metal illness. There is just so much stigma associated with it.
I have certainly bloggged about this phenomenon before. The stigma is even perpetuated by the propriatary, dismissive attitude toward mental health treatment by the medical community.
There are many initiatives by the goverment and insurance companies and administrative physicians and psychologist types (those that set policies, go to meetings, are 'indsipensible' and DON'T take care of patients all day) to basically "pigeon-hole" everything ie. all mental illness into "DEPRESSION".
It is leading to problems yet it is so politically correct becouse it looks like we are doing so much to improve mental health care delivery. It leads to problems, misdiagnosis, and improper treatment.

I believe we will hear more about this is in about a decade or so when the medical community at large and the policy-makers figure it out and start to notice that not everything fits easily into the generic catagory of depression.  But you heard it here first. I often see patients that have been so mismanaged by a primary physician, it makes my job much more difficult. Yes it is true the easy cases that have been managed well by primary care, never have any need to come and see me, the specialist. Yet through no fault of their own we are also putting more pressure than ever on primary care do diagnose and treat mental illness.
I am pretty politically incorrect in saying this because sometimes political supercedes clincal, and most people in adminstrative roles don't like to listen to my clincal concerns, or they 'know better'. At any rate I keep doing my best in properly diagnosising and treating patient and taking care of people., in my speicalty.

Now as far as these insanity and murder issues. Insanity is a legal term. It does not mean much from a clinical perspective.   Mental competancy, capacity etc- all legal terms. Manipulated by attorneys, used and misused to sway juries one way or another. Interpreted and misnterpreted by judges, lawyers and human beings serving on a jury. Human beings are emotional and feeling people, and every "good" lawyer knows that. There is really no such things as objective facts that are not processed by a human being with emotions, but that is courtroom stuff, see lawyer blogs for that.
Clincally speaking here are the relevent details,
A good psychiatrist in evaluating a patient and arriving at a differential diagnosis first must figure out if a person is psychotic or not. Psychotic means out of the realm of reality or "reality testing". Psychotic is not hard to decipher for any reasonable, astute clinician. It manifests with some certain specific basic types of signs and symptoms, some basic signs are hallucinaitons and delusions.
Hearing voices is a basic type of psychotic symptom, Once again for an astute clinician this is pretty basic and not difficult to diagnose.
I suppose the term astute is relative. I have evaluated and treated tens of thousands of patients in psychiatry, including lots of murderers, rapists and various other criminals.  So maybe I think it should not be too hard. The scary truth of the matter is, that many mental health practicioners don't know there butt from a hole in the ground when it comes to evaluating if someone is psychotic or not. Many family doctors perhaps even a majority, are also not competent in evaluating if somone is psychotic or not.
So with that said becouse I have many years of experience in doing this, it makes some people angry resentful and hostile. "How can you tell if somone is psychotic from talking to them for a few minutes" I can't say much to that except, you don't call a plummer when there is a leak under your car, you call a mechanic. Part of the reason it makes poeple resentful that I have expertise in this area, is those people tend to have a horrible prejudice about mental illness. They consider diagosing somone with mental illness as some sort of value judgement. Perhaps a judgement on character, and since I am diangostician, I am the "judger" in their mind. It is more about the stigma and bias and fear those individuals carry about mental illness. As you might imagine it does nto motivate people to go into or stay in psychiatry.

Anyways here is a BASIC concept with tremendous relevence to the current geopolitical climate in the United States.. When it come to delusions (fixed beliefs not grounded in reality testing). There are certain basic areas to always ask about. for example Pre-occupations with Religious, somatic, and grandiosity and paranoia.
There are certain areas of paranoia to always inquire about when performing a psychiatric assessment.
These certian sub-areas of content in paranoia for example include such things as aliens, mind control, satanic, religious and government.
This is something I learned all about over 20 years ago in my psychiatric training, It is something assessed in any competent psychiatric evaluation. It is something I have dealt with in patients and continue to deal with on a daily basis almost every day of my profesisonal life.
The concept of  paranoia about the government has always been a common theme in psychotic paranoia. not everyone with psychosis has this issue, but it is still common enough to always need to be assessed. It has absolutely nothing to do with the tea party, or Obama, or Bush, or Clinton, or Republicans or Democrats or Palin, or Beck, or Medow or Fox or CNBC. It has absolutely nothing to do with economic cycles.
The specific delusion may vary slightly with popular culture for example in the 1960's there may have been more psychotic people worried about martians or aliens from Mars when that science fiction was popular, in the 1980's there may have been more paranoid people worried about communists and Soviets doing bad things like planting microchips in ones brain while they slept. The point is psychotic paranoia is an illness and a common area of content involves goverment, mind ocntrol etc. Not new, not interesting per say, just a common area of psychitry, like a plumber fixing a leak, a computer tech fixing a slow hard drive.
Now when we talk of schizophrenia- a psyhcoitc disorder, that affects about 2% of the population WORLD-WIDE. That number is fairly consistent across cultures. In the USA that is 6 million people give or take a few. Did Glenn Beck or OBama increase the number of schizophremic people in the United States? Absolutely not. It does not work that way.
Most people with schizophrenia are not dangerous or viloent. untreated paranoid schizophrenia can lead to more dangerousness. Wow!  How can a person like the Tuscon shooter slip through the cracks?
If this person who killed those innnoecnt people and wounded others, had had a psychiatrist, most likely that psychitrist would have been blamed. Thats how we view things in the USA. But he apparently did not have treatment, so we blame the inadequate system.

It is flawed and inadequate, not question there.

The fact of the matter is, if you take that 6 million people, many are not treated, no one knows exactly how many, but say a million. Those untreated individuals are out and about living with parents or homeless, or in college dorms or sitting around with a bunch or dis-enfranchised 20 year olds smoking pot doing whatever,being paranoid, threatening, fantasizing, obsessing about conspiracy, goverment control, mind control, or whatever delusional material you want. they cause disturbance sometimes, post things on facebook and internet, and usually fly under the radar and don't act on their threats or fantasies. It happens all the time eveyr day and all over the country. No one can predict with consistent accuracy which one sending off signals and warning signs is going to act. There are a lot of people sending off warning signals as we speak, and sadly they are nto getting help or treatment. The only thing that predicts future behavior is past acts.It is not new to this political climate and has been happening for centuries.
Schizoprehnia starts when you are young. It is a chronic incurrable disease of young people typically with onset around 17-25 years of age.There is not a cure. It is treatable but not curable.
So what do we do?
The currect system is flawed. Yes lawyers and the ACLU and society in general wants to protect peoples civil rights. Yes the mental health system has committed abuses namely by neglect, in state hospital about 60-90 years ago. The pendulum has swung the other way. We have the media, angry reporters so mis-informed and condemming doctors, drug companies and the like. We have family doctors poorly trained in mental health and psychitatry or not trianed at all, trying to categorize and treat mental illness, and sometimes making it worse. We have very few young physicians going into psychiatry. In my community and in many communities we have untrained psychologists trying to pracitce psychopharmacology and advise family doctors how to practice psychiatry. The situaiton is unbelievable. We have psychologists and psychotherapists and the media and even certain members in the medical commiunity at large cristicizing psychiatry, and of course that coupled with very low pay compared to every other medical speicalty except pediatrics- For all the young doctors coming out of medical school. almost NO ONE wants to train in and practice psychiatry.

So what was going on in the mind of the shooter? Did he have schizphrenia? Most likely from the bits and pieces presented by the media. Paranoia is a projection of one's aggressive drives. Every single person has drives: eg aggressive drives, sex drive, hunger drive, but we are higher functioning psychological beings so we learn to surpress and repress and sublimate aggresive drives, we become social and empathic and compassionate beings hopefully. It takes some reaonsable genetics and environmental nurturing at an early age.
A person with schizophrenia may hear voices, they may become so fixated on their delusional beliefs that can't think about anything else. It becomes all encompassing. They become paranoid: that is thinking others are out to hurt them or kill then because it is too psyhcologically overwhelming and forbidden and destructive to deal with aggressive drives.  The process is highly unconscious. Sort of like dreaming.
A Psychological projection is what paranoia is. A primitive drive, a desire to hurt someone, projected onto somone else. "They want to hurt me" nothing new, a psychological understanding that has been around for a hundred years, that many therapists in this day and age do not learn or have a concept of,
generally viewed as a bunch of psychobabble BS. Except if you understand the psychological defense it makes a lot of sense.
In this day and age there is much more biological theory on schizphrenia than psychological theory. Dopamine, has been classically linked to schizophrenia, people with schizophrenia have structural changes in their brain that others do not, for example they have larger cerebral ventricles.
Twins raised apart in different environments from birth have a higher incidence of schizophrenia  between them. That is if one twin has schizophrenia, the liklihood of the other having it, despite different environments is higher than average probability- Leading to the theory that there is some genetic component to schizophrenia. Like Alzheimer's though, the exacct genetic links are not well understood.v Other neurotransmitter like glutamte and glycine and many others have been and are being studied,
Another way of thinking about schizophrenia, is that the mind of a schiophrenic is almost like someone without schizophrenia having a bizzare dream. There is no time relationship in dreams they are often weird and bizzare, and then you wake up.
Some data shows that people with schizophrenia when relaying the content of their dreams have very NORMAL dreams. that su what would be considered normal everyday life for somone that does not have schizophrenia. Dreaming is a psyhoclogical primary process. Another possible way to think about or understand schizophrenia is being in a bizzare dream where you can't wake up.   Only that person with schizophrenia is wide awake and conscious.

Well I could talk about this stuff all day. I wish there was less stigma, I wish the media could do more accurate reporting. I wish there was not always a political platform somewhere. This is my job, it is what I do. I often deal with dangerous patients and sometimes my life is life is at risk.
Mental illness and the inadequacy of the system only seems to get addressed ion the collecitve consciousness of Americans over situations like Tuscon. I wish the dialogue would continue, I wish the politcs were taklen out. Inevitably however, the politics will continue and the mental health dialogue will slowly die out over the weeks.

Hello

2011-01-12T11:30:00.000-08:00

Hi Doc,

Thought I stop by and wish all of your followers and your family, I am not sure about you though, a very happy new year.

For me it will get worse, last year things progressed, this year maybe I will forget all and have no resentments because I cannnt remember ther.

God Bless & Keep You,
joe

2011-01-02T17:33:00.000-08:00

I took my dad's 57 Chevy down to the assisted living today. When he saw it he said (paraphrasing) "That looks like the one I used to have." I of course told him it was his. I asked him if he would like to go for a ride. He said "Hell yeah." We drove around for a short time, he did not say much but he absolutely loved it. Today was a good day. I am attaching a pic. Thanks be to God.

Happy New Year- National Alzheimer's Project Act

2010-12-31T14:29:00.000-08:00

Well a Wish for a Healthy, Blessed and Happy and Safe New Year. God Bless All of you, Even the cool intellectual atheists, agnostics and everyone else that would have a hard time accepting the blessing. I go to mass nearly every Sunday, I won't begin to tell you my Christmas Eve Mass Experience at Holy Rosary Cathedral In Duluth, MN. My God it makes me almost feel embarrasseabout being Catholic, the way some of these middle aged narcissisits and their offspring and their offspring's offspring, behave in church on the one day a year they actually go to mass. Makes it very miserable and difficult if you just want to pray in peace. Shameful and despicable, and I promise you I am not being vindictive. And we wonder why our children and each subsequent generation is so mean and disrespectful. I get tired of being surrounded by 45 year old adolescents sometimes.- But I guess that's what the world is amounting to.

Just a quick note on the business at hand since this is an Alzheimer's blog. So both houses of Congress passed the National Alzheimer's Project Act. So now the president has to sign it. It passed on December 15th the house and the senate, and was sent to the president Barrack Obama to sign. He has ten days to sign it and if he does not sign it, while congress is in session, it automatically becomes law in 10 days. However if congress adjourns before the 10 days, (they adjourned on December 22,) and the president does not sign it, then it is a pocket veto. Now, I am no lawyer, did not go to law school, so I am sure I am missing something in the constitution. Perhaps it is already signed by the president and no press release, doubt it. It creates more government control, basically by forming a committee, to find a cure and effective treatment for Alzheimer's. The committee consisting of lots of federal goverment officials, and private sector experts in the field, will help oversee funding alotments foer treatment and research in the field. The Act in no way alots funding for Alzhiemer's disease, jst oversees it. So with more government control and oversight, I would expect the president to sign it. On the other hand I can certinaly think of many reasons why he would not sign it.
The head of the consortium woul;d be the director of the health and human services, Kathryn Sebelius a lawyer, or her disignee. As you might imagine almost everyone who is affected by Alzheimer's disease, is behind this, because it brings attention to AD. That is a good thing. The Alzheimers association loves it, obviously it would or could give them the chance to maybe even move into an important and powerful role on the committee, Wonder who wants to be designee.

If Obama signs it, then it would illustrate his dedication to the elderly, the ignored and the downtrodden, those people and families directly affected by the devastting disease. It would be counterintutitve if he did not sign it right?
I am very concerend about these congress and veto time constriants, I can't understand why the Alzhiemer's Association is not all over this, and the New York Times and everybody else. I must be missing something. These has to be some loophole, he must have lots of time to sign it right?

Mr Joe Potocny's Book

2010-12-09T22:32:00.000-08:00

I had the pleasure of receiving in the mail a signed copy of Mr Joe Potocny's book Living With Alzheimers' [A Conversation If You Will]. It is published by Xlibris and is 311 pages. It covers Joe's blog from September 2006 to Sept 2010. Joe has had almost 50,000 visitors to his blog and the book contains those blog entries and comments from readers over 4 years. There are hundreds of entries. It basically takes you through the life of Joe and chronicles the Alzheimer's he is living with. In addition it gives a little slice of his readers and what they are going through and how they relate to Joe's journey. We are all fortunate that Joe put this together, as it needed to be detailed not just in the cyber web land but in good old fashioned book form. He has it available in hardbound and paperback and ebook and kindle.
It is very cool because you can pick it up and turn to any page and find a moving blog entry. Or you can read it from cover to cover or back to front. You will pick it up and get a real slice of the Alzheimer's world and learn something. And like I always say, you don't have to be affected by this or have a loved one affected to pick it up and learn something. Congratulations to Joe on a job well done. He continues to wage the war, fight the fight, and make us all aware.

JOE'S BOOK AT AMAZON.COM

The writings & ramblings of a Philadelphian: VBT Author Spotlight: DR. J. Sivak

2010-11-24T21:42:00.000-08:00

The writings & ramblings of a Philadelphian: VBT Author Spotlight: DR. J. Sivak: "Good Wednesday and Thanksgiving Eve morning, everyone! :) Today, we have author and MD, Dr. J. Sivak with us, discussing his book, Whe..."

Stream of Consciousness Blogging Random Musings and other useful stuff.

2010-11-18T10:55:00.000-08:00

Tomorrow is set-up for festival of trees. We will have some helpful info from Local Chapter of Alzheimer's Association, thanks to Esther over at the Duluth office. We will also have Help info from the National Family Caregivers Association (0NFCA) thanks to Suzanne over there in the great state of Maryland. Yes I love the Crab Cakes over at Obrycki's. and the old water taxis to Fell's Point. Of course the state is not just a suburb of DC and the inner harbor, in fact the whole state is beautiful. I sure miss the crab especially since Brian Williams told us on the NBC news last night how filthy and carcinogenic the crab and all seafood is from Thailand and Viet Nam is, it makes me realize I could eat a lot more healthy in Baltimore than I could in Duluth. - probably more cheaply too.

Speaking of DC don't forget our president declared November 2010. From the White House: http://www.whitehouse.gov/the-press-office/2010/10/29/presidential-proclamation-national-family-caregivers-month
Yes the President signed a proclamation.
Don't forget if I actually sell a book or two at the Duluth Junior League Festival of Trees this weekend, I will be donating some back to the NFCA.
If you actually take the time to read some of this blog over the last year, you know how skeptical I am of big government, big corporate entities, including those of all tax statuses such as no profits. (Did you ever notice how many non-profits are located in and around the beltway-why is that?) However the NFCA really struck me as so important and meaningful and useful. It started with a real mission from real people and the beauty is, "it has not gotten to big for its britches", it really cares about a segment very often overlooked. that is the Caregiver. I very much respect them.
As far as the Alzheimer's Association, the real work still happens down at the local grassroots level and there are so many people working hard there with sometimes little day to day support and limited resources, but those local support groups make all the difference in the world. Those phone calls to the local chapter, offering information and support go so far. It is just good people working and caring down at the local chapter level. It is sort of where the "rubber meets the road". if you will.
My buddies Ken and Kathy Kollodge from the Kollodge have donated a Sunflower Photograph worth about $250 and a cubical art painting of a sunflower, (for your desk) which we will raffle off and give away Sunday to a lucky winner.
don't forget the sunflower is really important throughout history. The Aztecs sure liked it. It symbolizes many things including loyalty and wishes. I think which are extremely relevant things to the Caregiver.

In fact Ken is having an opening:
Ken Kollodge ice photographs at Art of Hair
from Duluth News Tribune:
"Ken Kollodge lived in Alaska for 30 years, and will be showing his photographs from the World Ice Art Championships in Fairbanks. Large blocks of ice were carved into sculptures, and Kollodge captured the patterns of light within the ice. They will be exhibited at the Art of Hair, 1427 London Road through December. The opening reception is 5-8 p.m. Friday."

The book tour writing blog continues. The diversity and individuality of people's blogs is quite amazing. Blogging is such a wonderful thing isn't it?

The Christmas City is the North Parade is Friday night, It is a big ole Duluth event. It is usually damn cold, but then again "the cold does not bother us" hmmm.
My little son, who is not little anymore, gets to march in the parade. He is playing sax, he generally only likes guitar and writing music, but the sax is okay. I encouraged him to take up Oboe, as I felt he needed a concert ssymphony instrument. He was okay at it, but generally ambivalent of it and suspicious as he was leery that is was too feminine of an instrument. Unfortunately the band teacher made him stay with it, as there is a paucity of oboe players in the concert band. However he has started Bassoon, which is more appealing it appears, and more masculine. with its tenor, tt is actually my favorite sounding instrument in many ways. In the end again his true love is first and only guitar.

I am still waitng for a copy of Joe Potocny's book, can't wait to read it, he is over at living with Alzheimer's blog.

Well enough stream of consciousness, if you are a caregiver, I hope you had time to read this mind idling stuff in this post and take your mind of your stress for only a couple minutes at least. I know the holidays are coming upon us and it is a particularly tough time for many caregivers, they still make me really sad in ways as I miss my parents even 25 years later.
If you are caregiving for a family member or loved one, or if you work in the caregiving world, God Bless you and as we used to say in 1974, Keep on Truckin baby.

Duluth Junior League Festival of Trees- Book Signing

2010-11-09T12:53:00.000-08:00

I will be at the Junior League Annual Festival of Trees in Duluth, MN on Saturday and Sunday November 20 and 21, all day, both days, at the DECC (Duluth Entertianment and Convention Center.) There will be a booth, with the publisher Niagara Press. There are hundreds of booths with vendors, selling everything from books to crafts and anything else might need for Christmas shopping ideas.
I will be signing and selling copies of "When Can I Go Home?" on both days. A Portion of the proceeds will be from the book sales and will be donated to the National Family Caregivers Association. which is a very relevant organization. Check it out.
There will also be a drawing for a painting from the Kollodge Art Gallery in Duluth. Ken and Kathy are really cook people and owners of that gallery. They lived in Alaska for many years before coming down to Duluth, so they have many insights from their life experience and it shows in their work. Basically anyone that purchases a copy of "When can I Go Home?" will be entered into a free drawing to win the painting. The winner will be drawn Sunday towards the end of the Festival.
I will also have some other helpful information about Alzheimer's available at the booth from the Local Alzheimer's Association as well as the publisher Niagara Press.
There is also a On Line Auction for the Festival of Trees, with all kinds of donated items. I donated two copies of the book for this auction. The Junior League has been around for a long time and for many decades has been a leading organization in the realm of volunteerism and giving back to the community.

Virtual Book Tour, Guest Blogging/ Author Interviews, Writer and Book Blogs

2010-10-31T20:56:00.000-07:00

Here is a List of Writer and Book Blogs, (really cool blogs) where I will be guest blogging or interviewed for Virtual Book Tour for "When Can I Go Home?"

1.       October 25 - http://virtualbooktourcafe.weebly.com/spotlight-features.html
(Virtual Book Tour Cafe Feature Spotlight) Book Tour Cafe

2.      October 27 - Guest Blogging at http://rhodesreview.com/
(Rhodes Review)

3.      November 2 - Guest Blogging at http://amomentwithmystee.blogspot.com/
(A Moment With Mystee)

4.      November 4 - Guest Blogging at http://cindy-vine.blogspot.com/
(Cindy Vine)

5.     November 6 - Author Interviewed at http://myimmortalstories.blogspot.com/
(Written In Blood)

6.      November 8 - Author Interviewed at http://consciousdiscussions.blogspot.com/
(Brummet's Conscious Blog)

7.      November 10 - Guest Blogging at http://writersmovementweb.blogspot.com/
(Writers Movement)

8.     November 16 - Guest Blogging at http://mizging.blogspot.com/
(Ginger Simpson's "Dishin' It Out")

9.      November 18 - Guest Blogging at http://www.armsofasister.com/
(Arms of A Sister)

10.   November 22 - Author Interviewed at http://onealmediagroup.blogspot.com/
(O'Neal Media Group Publicity News)

11. November 24 - Guest Blogging at http://harveyle.blogspot.com/
(The writings & ramblings of a Philadelphian)

12.   November 26 - Author Interviewed at http://walkermuse.blogspot.com/
(BK Walker's Musing of the Mind)

13. November 30- Guest Blogging at http://azpublishingservices.blogspot.com/
(Changing Face of Publishing)

14. December 2 - Guest Blogging at http://ashleysbookshelf.blogspot.com/
(Ashley's Bookshelf)

Human Communication- Part 2 Cyber bullying, social media FB Twit Narcissist Haven?

2010-10-29T23:17:00.000-07:00

The concept of anonymity was discussed. The lack of identity etc. You get to be whoever you want. The next major issue is how communication has changed, or lack of communication more precisely. Think about it, regardless of you religious affiliation, oh sorry Spirituality and beliefs I mean, you still have to consider human beings are mammals evolved animals. What sets us different? Opposable thumbs, of course and hence cutlery, and big old evolved brains. Huge brains with massive overgrown cerebral hemispheres, relative to everybody else in the animal kingdom. so what comes with that? Well verbal communication, It started out as eye contact then grunts and it evolved into words. Yeah we lost all the other cool senses and non-verbal communication that other animals still have with each other, instinct etc. (See "New Age Spirituality" of the last 25 years Metaphysical or whatever it is called in 2010. you can work to get some of it back it is actually not a special gift for all the clairvoyants out there, it is actually something old humans lost hold of.)
Anyway so humans evolve, we loose our old instinctual communication, we grunt, we speak we make up languages, lots of them, based on where we are geographically, sort of still around, global neighborhood etc, based on who invaded who, I mean why don't the British speak French as primary language. (Rhetorical).
Then you throw in the opposable thumbs, and we start drawing on Cave walls and we get symbols and signs. We can draw. We start to draw lots of symbols and make up symbols for those grunts that are now words. Verbal and now written language. We communicate through it.
The original verbal language of humans was very intimate. It was all about eye contact and gestures, just slightly beyond the other animals. you had to be in the same cave or vicinity to communicate. you knew where you stood.
The written stone tablets changed everything, you did not need to be in the vicinity of the person to communicate. Throw in ink and paper over the centuries, and finally the printing press. Communication became more massive, and less intimate. And nothing much went on for a few hundred years.
Then very recently, (relatively speaking to how long humans have been on earth) just the last two centuries or so, all hell broke loose. The telegraph, early 1800's really brought out the immediacy of remote communication. Then of course the phone, TV and radio, in only the last century.
The telegraph brought in immediacy but not intimacy. no eye contact, no inflection. soon the phone brought even more immediacy and a strange new pseudo-intimacy. Inflection, and voice but remoreness. No facial expression, no smells, no gestures. But lots of auditory.
TV really revolutionized the pseudo-intimacy. Now lots of one way communication, with two dimensional visual. and lots of sound. in your home no less, but still not real communication at least in a truly intimated two way human form. You can't bully someone through the TV, but you sure can demonstrate lots of it, even in high def now.
interestingly, people used to harass and beat the hell out of people over the phone, crank calls, etc. Just as the Internet, was taking off, some genius thought of caller ID and *69, and all of a sudden no more anonymous terroristic threats, people stopped playing games and harassing each other in that way.
Then emerged the Internet and simultaneously cell phones they sort of became the same thing as far as cyberbullying is concerned.
It was great we got rid of those clunky typewriters. Printers got better. We all learned how to type, if we hadn't in high school, except, the darn keyboard lingered as a remnant of the old typewriter. Now emerges the touch screens. Smart boards etc. Thank God for modern technology right.
The anonymity is back with the Internet, you really have no idea whom you are talking to or listening to. Sorry but you don't. Of course now we have the crude innovation of skype, That of course will only get more perfected, but it will still only be two dimensional, no smell, no touch, until we can do molecular transport like Star Trek.
So now we communicate with the Internet. At work we email somebody across the hall. Parents and kids text each other in the next room. Why is that? Because it is a lot of work to communicate with someone face to face, and we as a society have started to develop a distinct anxiety about it.
Probably as a society the only thing we are more phobic about than direct face to face communication and intimacy. We are probably lazier than ever as a society. Think about it video-conferencing has taken off V-tel and all that, but it will never take off as it could have by now at least in the workplace.
We will always go for real life face to face meeting, if it involves excessive travel, why my God we can't do a video conference for that, we have to go for London for five days for that one hour meeting. Because when you are traveling you get to get out of doing actual work, and still get to do all the self-aggrandizing- you know the type, always busy, gotta be somewhere. Check any airport.

The bottom line in communication is that it isn't what you say, it's how you say it. Or at least that is 50% of human communication. At least that is what I have told students and anyone else who wants to know the art of developing an empathic connection with a patient.
Eye contact, inflection, volume, gestures, body posture that is 50% of human communication.pauses, facial expression. We call these non-verbal forms of communication but in reality human communication is one entity, and those are all components of it. Anything less than that is slightly less than human, say something like the Internet and social media for example. We don't call it less than human communication though we call it virtual. But face it, when something is slightly less human isn't it easy to behave in a less than decent human fashion say cyberbullying?

Guest Blogger from Isabel at Enduring Care

2010-10-18T19:24:00.000-07:00

Here is a post from my fellow blogger and Caregiver Isabel. She has a great blog called Enduring Care and knows firsthand about caring for a family member with AD. She is a excellent writer and captures the essence of all this stuff, you will see what I mean......

Living in the Age of Instant (Non)Medical Diagnoses

In the millennium, televised medicine is all the rage. Colonoscopies are performed before a live, gasping audience, staged for national television. Patients are being encouraged to second-guess our physicians. Everyone, it seems, is a wannabe physician.

The old, “everyone wants to be a comedian” should be updated in the millennium to: “Everyone is an unlicensed medical diagnostician.”

Even in the days of “Dr. Ben Casey’s” fictional character on television, tv “medicine” realistically took longer than today’s “Hollywood-style” camera-ready medical practice. Plastic surgery? No problem! Aging? “Fuhgged-about-it,” as my New York City Italian friends love to say.

Our millennial medical madness trend is evident to me in a number of areas, including Alzheimer’s and dementia lay-diagnoses. Lost your keys? Alzheimer’s! Tired and at a loss for words? Dementia! “Ask your doctor about Aricept” for the treatment of Alzheimer’s disease “symptoms,” is the overarching message of one long-running millennial tv commercial. Piece of cake diagnoses and medical treatment await you and me, should we be so naïvely inclined.

In my younger years, I believe we called such thinking hypochondria. Back then, no reasonable person ever dared mention or conjure up chronic diseases, lest the individual were to tempt the universe to rain down illness in one’s life. Back then, hypochondriac thinking was frowned upon, or laughed out of town. In the millennium, we encourage and celebrate hypochondriac tendencies, more so about perceived or imagined Alzheimer’s and dementia symptoms. Some folks see Alzheimer’s at every turn – more so in the lives of others!

Dr. Sivak’s blog, Differences Between Delirium, Depression, Dementia, Delusions, Alzheimer’s, is a good read if any layperson feels a sudden urge to non-medically diagnose another individual’s “symptoms” as Alzheimer’s and/or dementia.

Cultural Perspectives on Alzheimer’s

I am part of the (Baby Boomer) generation that grew up accepting the generic use of the word “senility.” Back then, the word “senility” was used regularly by adults to define perceived “symptoms” of aging in some elders who displayed episodic or persistent memory loss, wandering behaviors, and, mental confusion such as currently associated with Alzheimer’s and dementia.

Oddly, although we were less medically enlightened in the 1960’s and 1970’s than we are today, many “senile” elders were not socially hidden by their families. Many families with “senile” elders revered their elders and taught their boomer offspring to do the same.

One of my childhood friend’s grandfather was “senile.” “Gramps” once walked half-mile, got on a bus, and wandered off – albeit in a kinder, gentler world. An entire community was on the lookout for “Gramps.”

“Gramps” was given a ride back home near dusk, when someone spotted him at the end of the bus line, confused, in a city more than 15 miles away. When “Gramps” was safely back at home, my friends and I asked him where he’d been. We listened to his sharing and laughed when he laughed. “Gramps” was physically fit, cheerful, otherwise seemed to be in good health, albeit cognitively lost quite often. Gramps died in his 90’s, in his adult daughter’s home, surrounded by his grandchildren, neighbors who’d looked out for him, and, other loved ones.

Medical Advances in Alzheimer’s Treatment and the Great Social Divide

Social progress is a funny thing. Are individuals who have been medically diagnosed with Alzheimer’s in the millennium, more, or less, socially visible than those in Gramps’ generation? You decide.

How far have we come in our public perceptions of Alzheimer’s?

· Public education and awareness may be at all-time highs, yet, there are some communities that have yet to realize that Alzheimer’s disease is fatal. Might some individuals be in social denial?

· Whether due to social over-simplification of symptoms or over-use of medical terminology by laypersons, there is some tunnel-vision in recognizing possible symptoms of Alzheimer’s and related brain diseases. Some individuals pounce at “senior moments” of lost keys or forgetting the day of the week as “evidence” of Alzheimer’s or dementia, while missing the medical forest for the laypersons’ trees.

· Some may view the lack of a cure for Alzheimer’s as the final word. “Senility” happens, and there is no cure, so why bother, may be the prevailing thought for some individuals.

Regardless of how far we may have come, some individuals may still be circling the wagons. Dr. Sivak’s blog says it all for me: “Lots of D’s to differentiate.” While we’re at the letter d, please talk to your doctor. This is not your grandfather’s generation. It’s the millennium.

There are medical treatments that have been proven to slow the progress of cognitive decline. Aren’t you the least bit interested in hearing?

IsabelCares

http://enduringcare.typepad.com/my-blog/

Twitter: https://twitter.com/EnduringCare

cyberbullying, social media, facebook, twitter, a haven for narcissists? part 1

2010-10-16T10:39:00.000-07:00

So what is all this cyberbullying really about? Has it always been there, the concept of bullying that is and now there is just another really convenient outlet in social media? Is it getting worse? Have teenagers always been attempting and committing suicide because of the vile ways they are treated by other young adults? Are we just more aware of it? Is it just in our faces more because of the instantaneous virtual connection and immediacy of the Internet?
There are so many frameworks to understand it, yet it is still not understood well, we know it is bad, but we don't know how to really stop it as a society. There are maybe three things to think about in terms of this whole problem. The concept of anonymity, communication, and narcissism.
Think about it, you really have no idea on social media outlets, on the Internet for that matter exactly whom you are communication with through the concept of electronic printed word, that's why it is called VIRTUAL. With the concept of true anonymity, anyone can be anything and anyone they want. It is amazing how many people lie about who they are and what they are, but that was happening long before the Internet, but I think it is safe to say the Internet really propelled that pathology forward by light years in just a couple decades. Why would someone do that?
Well we like to think a person just feels bad about themselves, low self-esteem, etc etc, yes that is true, that why people brag and boast. But it is deeper than the everpresent low self esteem. The reason the self esteem is low and the person is constantly lying trying to reinvent themselves, it isn't low self esteem, it is more that there is really nothing there on the inside at all, a big hole of emptiness in ones sense of self. The sense of self is a big lofty concept, but it also sounds quite simple. It is our sense of reality of ourselves and the world around us. It is our sense of who and how and what we are in the world and how the rest of the world (people) relates to us. That is our so called "ego-strength". The more developed ones ego strength the better they can cope relate and navigate through the world. Now when someones ego is developed in a healthy way, it gets really sophisticated in that when that is developed the next thing that develops is a sense of right and wrong, in reference to the world and others. Unless you have a true sense of self, a sense of right and wrong the so called "super-ego" can't really develop. How we relate to others in the world is our so called "object relations". Pretty much all these things start to develop and build upon one another from the time a person is coming out of the womb. an infant has no sense of self, they pretty much think the mother and they are the same thing for the first few months of life. no separation, no boundary. Pretty much everyone figures out they are a separate entity, right. To psychologically separate is a lot harder and a longer process through the early years.
What does all this have to do with the anonymity of the Internet and social media and cyberbullying and teens? Well the teenager struggles with their identity, their ego there sensee of self. They learn to think abstractly, they have to figure out how to go from childhood to adulthood. The have to figure out how to use their super-ego (The sense of right and wrong) if they ever developed it ( comes FROM the PARENTS) to get through the world. Every teen struggles with identity and sense of self, it is a growing period. It is all based upon how things went in those first ten or twelve years of life.
We hear the old adage"he is she is basically a good kid- he or she just got into the wrong crowd" Well hears news, Every kid is basically a good kid, no one ever asked to be born right?
so since every teen struggle with their sense of self and identify, isn't it cool to have the Internet and facebook and YouTube and myspace and this and that and the other thing to help facilitate that? You can be whoever you want, who cares, it's really right? Well virtually anyway.
you could see how the anonymity and the flip side of the coin VIRTUAL INTIMACY and connection really helps the old psychological developmental process along in the teenage years. Oh and it is really immediate and convenient too. But it is just you and your computer, or laptop of iPhone or whatever, and you are pretty much cut of from developing and sense of object relations or really how to get along or connect with other people when it is so important to refine in those developmentally turbulent adolescent years. Just the kid and his keyboard hmmm, sounds pretty powerful and omnipotent doesn't it. Well at least virtually. Hmm with that in place why would there not be cyberbullying? Throw in the communication issue, (the only form of human connection be it physical, spiritual, intellectual, or virtual communication it is connection, but what about virtual?

NB: when I use the term omnipotence or all powerful, (sitting at the keyboard), it may be derived from then anonymity, or that bubble or shell around the person, it is the same concept as why some people are outrageously aggressive people when they drive, Road rage etc. There is a false sense of power and security being in a car and as such the keyboard and the Internet.

antidepressants and suicide

2010-10-13T14:23:00.000-07:00

Popular hype. do they increase risk of suicide? Not a new concept, been around since antidepressants were around. Yet some seem to find antidepressants more sinister than depression, schizophrenia, ptsd, hmmm they all have an increased risk of suicide right. Generally untreated mental illness can have a fatal outcome. Sometimes it is just really debilitating, and causes a lot of suffering.
so we have mixed reviews on antidepressants, some studies showing a slight increase in suicidal risk when on these meds.
Here is a fact, meds are not there to hurt people or make them worse or make somebody kill themselves.
There is very little data on if and how many lives antidepressants save. I mean think about it, how can we really research that.
Not to mention the fact that there is more media hype on the dangers of antidepressants than on the fact that alcohol is associated with most completed suicides.
Hmmmm.
So the meds prescribed by doctors to actually prevent suicide may increase the risk, even a little bit?
First of all if they were truly dangerous, would not your wonderful Federal Government that we all know love and trust pull them from the market??
Lets say you are a liberal and you love big government, you have a nice 401k and cheap or free health insurance, you have enough money to afford to be liberal, generally speaking, you by default hate doctors, are suspicious and mistrusting of them and perceived authority and you really groove on the concept of these meds being dangerous prescribed by mean non-caring doctors, okay fine, but you love government, and generally vote in the direction of bigger government. If that was the case, think about it, WOULDN'T THE GOVERNMENT PULL THESE MEDS OFF THE MARKET IF THEY WERE TRULY DANGEROUS???? oh sorry I forgot it is the big bad drug companies that are out of control, and the government just has to control them better?
Well you see all the political issues involved here.
Anyways, since the government put out stern warnings on suicide risk of these meds in people under say 24 years old, it scared the hell out of doctors and the teen suicide rate has been climbing ever since. SAD. Doctors afraid to treat, afraid of getting blamed and sued? Maybe who knows.
What is known clinically and generally still accepted is this, when you start and antidepressant the vegetative signs of depression improve before the cognitive signs. Generally in the first couple weeks.
This means a person with depression responding to antidepressants gets their energy back before there sad hopeless suicidal thinking improves. So they actually get enough energy in those first few weeks, to kill themselves. A risky time. Not new, been around and clinically known like forever, The patient must be monitored closely in those first few weeks. Something your health care reform does not like much. The suicidal thinking does improve for many, if not most people that are depressed and get adequately treated. That is assuming you have the CORRECT diagnosis of major depression , the person is sober, and actually following a treatment plan prescribed, hopefully by a physician. It also helps for the person suffering to have a decent psychotherapist, that does not have a chip on their shoulder about meds and psychiatry, and actually some understanding of the expectations and limitations of meds, and not just what they read on the internet or heard on TV. See my earlier blogs.
What if these meds really were meant to help people, actually saved some lives, and were prescribed by doctors who knew how to diagnose and treat and had their patients best interest at heart and were trying to help them because that was their profession and their vocation and that's what they do all day? That is just no fun to believe? Or we actually know better than that, cause we do.
I just wish we did not want to have are cake and eat it too. If we could just take these medications seriously for a minute, we devalue them, yet evetrybody wants to prescribe them with a minimal amount of training. So which is it? And yes we all know many terrible stories, of the bad med and the bad doctor and the terrible things that happened because of the meds. There are 100 of those stories to one, wear somone actually is allowed to speak out on how medicaiton actually helped them.
And no meds are not the panacea. no one is saying that. Frankly they have profound limitations but they actually do save lives whether we want to admit that part or not.

Some things you may not know about antidepressants.

2010-10-08T09:22:00.000-07:00

Antidepressants have been around for fifty years. The first one was imipramine. How they work on the brain and central nervous system has not really evolved much over the last fifty years. Our understanding of why and how they work has evolved, and the bottom line is we still don't know exactly why or how they work. They tend to effect neurotransmitters in the brain, that is the chemical connections between nerves. The three big neurotransmitter we know the most about are serotonin, norepinepherine and dopamine. The old and most of the newer antidepressants inhibit reuptake of these neurotransmitters into the pre-synaptic nerve. The original theory on why they work was related to the fact that you kept more serotonin or norepi around and this somehow helped treat depression.
Then in the 80's, 90's and into this century more attention was paid to the area on the nerve cell where these chemicals bind to. The so-called synaptic neuroreceptor.
For a long time it was felt that because you kept more of the neurochemcial around and it moved forward from the presynaptic to post synaptic nerve site, that somehow the neurorepceptors got desensitized or "downregulated".
Over the last 10 years the theory has evolved even more as to why these things work to treat depression and many anxiety disorders.
Now the science has led us to believe that the binding of the neurochemical (caused by keeping more of the chemical around) cause changes within nerve cell and somehow this affects the genetic coding of proteins within the cell, (remember RNA and DNA?) and somehow this causes an uptick or a positive swing in encoding for proteins within the cell that help protect the cell and treat the depression or anxiety problem.
The theory continues to evolve.
Some other facts- most antidepressants are prescribed by primary care physicians, internists, obgyns, and even pediatricians. Yes psychiatrists prescribe them all the time, but there are a lot less psychiatrists, and in terms of total volume of scripts, more come from primary care.
For many reasons, culturally speaking, it is much more socially acceptable to be depressed now. We are more open to talking about it and being aware of it. Depression is still debilitating and potentially fatal and we have a long way to go. Primary cares screen for it better now.
Within the demise and so called restructuring of the health care system in this country, there is much buzz and initiatives to screen earlier, treat and be aware of depression and its consequences.
The problem is now in screening for it, there is a tendancy to diagnose most mental health problems and simplify them simply into depression. The screenings will pick up symptoms of depression, but often not the specific and primary mental health problem. for examply Bipolar disorder (horribly misdiagnosed) and often missed and PTSD or post traumatic stress disorder, to name just a couple.
There are a whole host of antidepressants out there, the SSRI's which were developed back starting in the 80's with prozac, then in the 90's and into this century. Zoloft, Paxil, Luvox, Celexa and Lexapro.
The SNRI's which stands for selective noradrenergic serotinergic reuptak inhibitors, Effexor, Cymbalta, Pristiq. Basically these work pretty similarly to the old imipramines and elavils of the 60's and 70's, with a couple huge differences. The newer ones have way less side effects, and they are not so lethal alone in overdose. They are also felt to be more effective by many, compared to the old ones, -which may be a product of the fact that they are eaiser to take and tolerate and stay on since the side effects are better. The key to antidepressants working, is staying on the meds. They don't work if you don't take them.
Antidepressants have been used to treat chronic pain almost for thirty years. It was generally off label meaning the FDA did not approve or recognize these things in use for chronic pain. Then the popular media campaign came that "depression hurts" and cymbalta being approved for various pain problems a few years ago. Sometimes they really work well and sometimes not for chronic pain.
You do get more physical aches and pains and such if you are depressed. That is not new and has been known like forever in the medical world, well at least the psychiatric medical world.
Antidepressants are not there to hurt a patient or make them worse, and they do save lives. We are taught as a society to be afraid of them, suspicious of them and wary of them. Popular culture and media and the government regulation and subsequent media fiascos make this worse.
Conversely we are also taught and expect that these meds are a panacea, a cure a fix it all for all of our emotional and psyhoclogical pains. That simply isn't true. But with those two polar ends of the spectrum suspicion, fear, and an attitude of this "should fix everything', you have the perfect storm.
There are many other antidepressants out there I did not mention, so that block certain receptor sites like Remeron and Serzone and Trazedone. They have also been around for years. Wellbitrin tends to block reuptake of dopamine and norepi. Some people generally like Wellbutrin becouse it does not affect weight gain like some of the others can. It sometimes does not work so well for anxiety symtoms often associated with depression.
There is a ton of information on antidepressants on the Internet. We tend to love the devaluation of them, and when we find a negative article on them we like to say "Aha I knew it" as if they are bad and there is some awful conspiracy. Some psychiatrists have even made a cool name for themselves in devaluing them. Very politically correct. We also tend to devalue them in this way:
Think about it: the average family doctor has a few weeks of training in psychiatry but they prescribe the most antidepressants. Non-physicians prescribe them- nurses practicioners, in most states and also psychologists want to prescribe them and in a couple states they are actually legally allowed to.
We convince ourselves that is all okay. It is not. This comes from the shortage of psychiatrists. Most doctors don't want to go into psychiatry. For a lot of reasons. It is very little pay compared to most medical specialties, with health care reform that will only get worse. Also people don't always get better, it takes a long time and a lot of psychiatric problems tend to be chronic and recurring.
so you will see more unqualified and marginally qualified people prescribing and treating psych disorders.
The sell-out blogs jump on the politically correct bandwagon of supporting psychologists and the so-called mid-level practitioners, prescribing, as well as non-psychiatric physician. With that comes an underlying devaluation of psychiatry in general. You are not allowed in this day and age to even consider that maybe a specialist in psychiatry should be treating many psych problems out there. That is so politically incorrect, you get lambasted and you are very unpopular, so most doctors can't even speak up any more. It is just the way the world is. But with the sort of disdainful reduced attitude towards psychiatry and mental health issues in general, and the lack of accurate information that is truly disseminated, it is easy to see why we are so wary of psych treatment.
Before I get hate mail yes there are good nurse practicioners out there, just like there are good physicians out there.
Generally the popular buzz is "doctors don't talk to their patients, but nurses do". I am sure that is true in some case, but we like to convince ourselves that this is the norm. It is probably going to get worse with health care reform.
Antidepressants are used in Alzheimer's, People with AD can get depressed, it make the AD worse. They often can't articulate it to us, becouse of the dementia, so it is often overlooked. You generally have to use much smalled doses of antidepressants in the elderly (like any med) sometimes if not carefully prescribed or prescribed wrong they can make things worse, and if diangosed right and carefully monitored they can help tremendously.
There is much more to talk about with antidepressants, the suicide issue (horribly misunderstood) side effects, target effects, (what they are actually supposed to do. All of the natural remedies, (chemicals also like the meds) they are a financial; boom to many and severly unregulated, but as a fairly uninformed society or shall I say misinformed, if we hear the world "Natural" we are profoundly reassured. Stay tuned.

Differences Between Delirium, Depression Dementia, Delusions, Alzheimer's

2010-09-24T10:38:00.000-07:00

Lots of D's to differentiate.
Alzheimer's disease is one form or type of dementia. The most common form or type of dementia. Dementia is the loss of cognitive ability. A global generic term. There are many other causes of dementia besides the most common Alzheimer's disease. Lewy body dementia, Vascular dementia, traumatic brain injury induced, to name a couple.
The different forms of dementia may look slightly different in their clinical symptoms and presentation and progression.
Dementia is a chronic problem it is typically slow and often progressive.
Delirium is way different. A delirium is an acute confusional state, or an encephalopathy. It generally comes in pretty quickly, hence the term "acute". There is always a cause for delirium. It may be a metabolic problem, eg. not enough oxygen to the brain or too much carbon dioxide, such as someone with really bad lung or heart disease, or a metabolic problem, someones sodium for example is too high or low, or a toxicity, such as illicit drugs or drug withdrawal, alcohol withdrawal is a common cause. A severe infection with for example a high fever is another cause.
Delirium is always a medical emergency. It can have a high death rate up to 25% or more, especially if not treated. Usually it is very treatable, the issue is diagnosing it and finding the cause.
Often it is mistaken for a psychiatric problem. A common symptom is visual hallucinations, seeing things, example bugs crawling on the wall. Sometimes there are tactile hallucinations, feeling things that are not there, such as bugs crawling on one's skin. These kind of hallucinations usually again indicate an "organic" or medical reason and problem.
A person can get extremely agitated in delirium, bizarre, violent aggressive behavior, it often gets worse at night and fluctuates over the course of the day. Sundowning is a term that has been associated with delirium.
A person with dementia can get agitated and worse at night. We also associate the term sundowning with Alzheimer's also, or more agitation at night. Wandering about etc.
A person with dementia can also develop a delirium on top of that. A common cause for example is a person that has Alzheimer's dementia and develops a urinary tract infection, or a metabolic imbalance.
That is where it gets more difficult to diagnose. Usually there is more of an acute change in the persons behavior, a significant worsening or change over hours or a few days.
One of the key things in telling the difference between delirium and dementia is that a person's level of consciousness fluctuates in delirium. They are in and out of consciousness, from awake and alert to sleepy somnolent, to hyperalert and agitated. Sometimes they are difficult to wake up, and may go from sound asleep and difficult to rouse to extremely agitated in a matter of seconds.
A person with dementia typically will not go in and out of consciousness so abruptly. They will be awake and alert, maybe completely impaired with memory, concentration, orientation, but they will be alert.
Another key thing is since delirium is a medical or organic problem, a person with have "autonomic fluctuations" This means there vital signs will fluctuate a lot over the course of the day. Remember it is a medical problem. So their blood pressure may go up and down they may have fevers that come and go, pulse rate may fluctuate. In someone with dementia only, you would not see much fluctuation in vital signs on a daily basis. But if they are not checked you would not know.
It is something a doctor (or medical provider) really needs to diagnose and find the cause of and treat.
As I have stated ion previous blog posts auditory hallucinations are typically associated with a psychiatric disorder, that is "hearing voices" of people that are not there. Unfortunately visual versus auditory hallucinations are not always distinguished by medical people outside of the psychiatric realm of specialists. Hence you can see another reason why it gets confusing.
Delusions are a symptom of psychosis. They are false ideas or beliefs. They can be of different types. Paranoid- eg "aliens planted a computer in my brain" or Ssomatic (physical) there are snakes in my belly eating my insides" Delusions are typically asassociated with a psychiatric disorder, such as schizophrenia, they are fixed and ongoing, however they can also develop in someone with dementia. And in fact are not uncommon as Alzheimer's disease progresses.
Delusions can also be seen in a delirium, but there are so many other things going on when a person has a delirium a fixed delusional belief is usually not a paramount symptom, since the whole medical problem is quickly developing and acute.
The paranoia associtated with for example Alzheimer's is a little bit different say than someone with schizophrenia. The false beliefs in dementia, may be more variable, and less fixed and tend to come and go, more than in a functional psychiatric disease.
but the issue of delusional beliefs is one of those quandaries that makes everyone ask is Alzheimer's a medical or a psychiatric problem (see previous posts).
The delusional material is often treated with anti-psychotics, it may not completely go away, but the person tends to be much less obsessed concerned with or likely to act on their delusional beliefs if they are treated. We then run into all the problems and well publicized issues with antipsychoitcs and the warnings in the elderly etc. (see previous posts).
Hallucinations are also treated with antipsychotics, they are not quite so common in dementia but certainly can and do occur, maybe not as often as delusional beliefs though.
you would not want to start treating visual hallucinations without simultaneously find the cause of any delirium. Auditory again are more common in psychiatric disorders, and it is less likely to find a delirium or medical cause, so the hallucinations are treated there also, and often respond quite well to antipsychoitc meds.
Depression is a psychiatric disorder, that is now more openly talked about over the last 15 years or so, so it has made its way into the mainstream of primary care and is regularly more screened for in general medicine, It is much more socially acceptable to talk about depression. Depression can have a high morbidity- loss of job, divorce, substance abuse) and be fatal for example by suicide if it is not treated.
Persons with dementia can also develop depression, but often unlike someone without dementia they can't necessarily tell us about it or how bad they fell because they are already cognitively impaired.
Here is where it gets even more tricky. Back in the day not so long ago, there used to be a common term called "pseudo-dementia". It was associated with depression. In fact it still is, but the term is no vogue anymore. Probably too confusing for everyone. Here's what it means- a person with depression has lots of symptoms- sad, hopeless, helpless, suicidal, insomnia, low energy, weight loss, for example to name a few, but a person suffering from major depression can also be cognitively slowed. They can be sluggish in memory and thinking. It can be mistaken for dementia,
As a person ages they are at increased risk for developing Alzheimer's, but if they are depressed and have absolutely no dementia, they may still have cognitive slowing from the depression and be misdiagnosed with dementia. IT HAPPENS A LOT. With the health care debacle it will happen even more as we will tend to want to diagnose ourselves or have our friends do it. This is why a medical work-up and psychiatric work up and evaluation is so important.
With health care rationing already here, I am very fearful that there will be many people misdiagnosed or simply not treated. People with Alzheimer's being misdiagnosed with depression and vice versa
Now one final problem, a person can have Alzheimer's disease brewing and depression at the same time. In fact depression can be the first sign of Alzheimer's. The diagnosis of one or both has to be made and differentiated by a medical professional. untreated depression can make the Alzheimer's worse.

The Double Whammy

2010-09-20T10:37:00.000-07:00

Most of my posts in the past have been about my dad and his battle with dementia but today going to talk about my mom. We have known that my mother has been having some memory problems herself, dating back for the last 1.5 to 2 years, roughly. So, in August, we took my mom in for a neuropsychological evaluation. The results came back with a dementia diagnosis, significant cognitive impairment, likely Alzheimers type dementia. So, mom and dad, ages 70 and 72, both have dementia. The double whammy. We have now started mom on the same memory medications that my dad has been on, so hopefully that will slows things down. But the whole situation remains very difficult for me to wrap my mind around.

Another thing that has occurred to me recently is the number of head injuries my dad may have had during his lifetime. He played a lot of football during an era of thin leather helmets, and his occupation left him open to physical injuries. I can remember his head being cut or bloodied many times. He also rode motorcycles and for a while semi-pro, he once had a wreck in which his jaw was broken and his teeth had to be wired shut for several weeks. Leaves me wondering how much of this accumulated history may be impacting his current condition.

The other news is that we have moved my folks to a new assisted living/dementia care home. The place is significantly nicer and we hope that they will be much more comfortable there.

Thanks be to God....JP

As The Present Fades

2010-09-14T13:35:00.001-07:00

I am still amazed at this point that I can still converse with you and tell you how things are going in my journey or battle if you will. In the beginning and still now i am prepared for the mental walkings and goings but I was never prepaired for the physical problems. Walking with a swagger, actually kind of a stumble and hunched, feeling icky most of the time, getting exttermely upset around people and sweaty like a pig, shaking like i do, not able to hold things all the time, just not ready for this crap.

I find my world in fading in and out now. I recognize family and people and suddenly they start to become someone else. Same person standing there but my brain seems to switch off and step back and say who the fuck is that. I am finding this to be happening more and more, I feel like i am fading away from Joe and going somewhere and I cannot stop it anylonger. I really wish I would hear from others in this world of mine and what they are going through and how they feel. It is really a lonely place, yes I have people around me that care and help, not the same, they are not here with me, in my reality such as it is.

I must go now my mind is confused and i am getting very angry.

God Bless You & This Country of Ours!

joe

PS. Hi Doc, this is from my blog today, love you my friend.

Remembering

2010-09-10T12:56:00.000-07:00

Well it is back to school time. N Minnesota saw a really hot summer. On the Western Terminus of Lake Superior it gets hot a few times every summer, up around 90 degrees. But it only lasts a few days here and there. This summer it was hot in the 80's for days on end, sometimes for weeks at a time. By American standards that is not really much, considering how warm it gets in other parts of the country. Right after labor day, it was like instant fall. Now it gets cold for the next 10 months. The temperature correlates with peoples attitudes. I mean the cold grates on you, I don't know how Canadians do it. Yes you can always wear three coats, bu t it still wears you out spiritually. Most people that live in the cold, pretend it does not bother them, or they are not even aware how it affects them. We like to think about the daylight, and seasonal affective disorder, and the pineal gland and melatonin and all that fun stuff, that has modest scientific review. Yes it does exist, but nobody really considers the cold.
Well we will try avoiding using the furnace for as long as possible. Hopefully can get another month in.
Lots of unhappy anniversary dates in September. It is exactly 10 years ago September 10, since I ruptured my Achilles tendon, simply paying tennis. That seemed to take forever to get better. Then on September 12th it will be exactly one year ago since I broke my face in three places falling off a scooter. See old blogs, hard to believe this blog has been up for over a year already. My face still hurts. I still don't know how I went back to work in a week back then , if only out of necessity.
Then a few months ago in going through my mother's old scrap book, I found out it was September 10th 1933, when she was in a tragic car accident. She was 16 and sustained a fractured skull. Interestingly she was back to school in a couple week after being in a coma. See old blogs about head injuries and development of Alzheimer's.
Then of course we have 9/11 for all Americans, 9 years and we all remember what we were doing when we heard, I know I do.
On the good side of September we have the start of football season. Nice night for the Saints and the city of New Orleans last night and not too good for local fans around here as the Vikes take a hit.
Well as the seasons continue to fly by, take care of yourselves, as a caregiver you still get to be human. Remember the day is only 24 hours, unlike the legendary Alzheimer's book says, you will all make it. The days grow shorter now, except for our friends in Australia and N Zed. If you live in a place where the leaves change, get out and take a serious walk over the next month and enjoy it. If you can take your loved one with you safely, then go for it, or just go for a drive. Everyone likes to go for a ride. The kids, the dog, people with AD. Where I live interestingly it goes from green to white. In other words sometimes it snows before the maple trees even turn yellow and orange or think about loosing their leaves. But time keeps marching on.

Alzheimer's and old memories, memory loss, long term memory preservation

2010-09-03T11:47:00.000-07:00

One of the important aspects about Alzheimer's disease and memory loss is the fact that the last part of the memory to decline is the long term memory. In other words your loved one will not remember very recent things,, from the here and now, what they ate for dinner four hours ago for example, but they will remember stuff from forty or fifty years ago quite clearly. Sometimes they can remember events from the 1950's or 60's like it was yesterday. There is trouble storing new and recent memories, but the old ones last a really long time in the disease process. It is just the nature of how the disease process works.
They might not know who the current president is, but they might remember some interesting things about JFK or the moon landing or even Pearl Harbor if they are old enough.
You might use this to connect with your loved one. Music is a wonderful area where long term memory is preserved, and it generally calms the mind and soul to hear music "from our time".
Old photographs also can sometimes stimulate mood, memory and the spirit.
It is a strange thing for people to see and observe sometimes, how can you not remember what day it is or what month, but you can tell me the name of your third grade teacher?
Ultimately the long term memories will also decline as the disease progresses, but use them while you have them. It is freeing and a wonderful way to connect. Don't worry if the old memories are not exactly accurate, just connect to your loved one through them.
You might even learn something historical and interesting that you never would have known had you not tried.

The Author's Show- Tuesday August 24th all day

2010-08-22T23:31:00.000-07:00

I will be on the Author's Show This Tuesday August 24th.
Interview with Don McCauly

Click on The Link Below to Listen:

The Author's Show Internet Radio Program

Sorry link works now.

Is Alzheimer's a mental illness ????

2010-08-20T12:56:00.000-07:00

This seems to be such a common question and issue. Everyone wants to know the answer. I have blogged about this in the past, but the question still comes up all the time. If it is not a mental illness does that make it better? If it is a mental illness, well does that somehow make it worse? Does it make AD less real if it is a mental illness.

When my mother developed AD, it was so shocking, so furious, so heart-breaking, I don't remember ever really pondering that question, because I was so overwhelmed, so bewildered, my head was spinning. Being seventeen at the time, it felt like I had a million things on my mind already. The whole process was like a waking dream.

My book "When Can I Go Home?" speaks to that waking dream. It also speaks to the process of me becoming a doctor and a psychiatrist- much of that process happened while she was dying from the disease.
For me a related question is, did I ultimately choose psychiatry as a specialty, because my mother had AD, and she had it long before I was anywhere near going to medical school.

I mean I could have entered and specialty right? God knows my life would have been a lot different if I had. Life would have been a lot less of a financial struggle, I would not have faced so much disdain and prejudice, because of the horrible stigma we place on mental illness. That stigma is why the question of AD being a mental illness is so important and why we place so much emphasis on it.

People with mental illness face it every day. It is parallel in my world. Let me explain what it is like. For so many people there is something uncomfortable, disquieting, "icky" about being a psychiatrist and mental illness in general. When someone learns a person is a physician, it immediately conjures up biases, stereotypes, preconceived notions. People might think you are smart, hard working, or a weasel, that your are no better than them, and all the usual chip-on-the-shoulder things and biases we have about physicians. Some still respect you as a person more than if you were not a physician.

But as soon as you advise your are a psychiatrist, my God, do peoples' expressions change. Many people get that "icky" disquieting feeling. They are also let down in some fashion. The ideal of a physician and all the underpinnings is gone. "Not the same as a real doctor"

Why do we consider the whole concept of mental illness as something subhuman, something more related to morality than a clinical manifestation? In our prejudicial minds the leap between someone having mental illness and their questionable integrity and questionable character is not a leap, but a thin blurred line.

So if you are a good person with good character from a family of good and decent character and someone gets AD, does that mean somewhere along the lines there was a breech of character, someone did something wrong? If it is NOT a mental illness then no intergrity or character issues right? Sort of off the hook. Moreover if it is a mental illness, then on some level would that not mean it is less than real- at least in the sense that if the person tries harder, than maybe it will go away. If we just figure out what that character flaw is.
If you have mental illness you know what it is like to be treated a little bit less than human, to have your character called into question, that prejudice, that bias, that icky feeling and manner other people present to you because you have mental illness. If you don't have mental illness, imagine what it would be like to have to live with that bias. I mean real imagine it for a second.

So AD is not a mental illness or a "functional" illness in this way: You can see it, you can find the amyloid plaques, we are moving closer to being able to test for it- checking spinal fluid, biomarkers. Therefore it is legitimate. It is real. We have tests and we can tangibly SEE it. But here is the problem, this is why we want to know if it a mental illness. We as family members are in the twilight zone. A gray area:

The everyday CLINICAL world lags behind the RESEARCH world, by 10 or 15 years.
Right now you can't routinely see it on a blood test, or a really good MRI or CT, you can see non-specific atrophy of the brain consistent with it, but you can't really definitively see it, unless you look at brain tissue on an autopsy, after the person has died from it. At least in 2010, thats the everyday reality we are all faced with.

Here's how Alzheimer's is a mental illness is 2010. We can't really see it on an x-ray or any blood test that you or I or most Americans may have access to. Nor with the deterioration and reduction of health care delivery, non of us are going to have much access to the evolving sophisticated research anytime soon, the same research that politically helps legitimize Alzheimer's disease.

-Alzheimer's disease affects behavior, actions, thoughts feelings personality, cognition, a persons manner of relatedness to others, all those things we conventionally equate with "MENTAL ILLNESS.

My mother had changes in her personality, and behaviors, sometimes it was odd, sometimes bizarre, sometimes not, but there were changes. Most AD victims do have these at some point. AD makes your brain deteriorate. You brain regulates behavior, personality, something has to do this and it is the brain. behavior and personality are not random or coincidental happenings.

A neurological disorder is so legitimate, a psychiatric disorder is not legitimized in our society.
The best answer to the question is "Alzheimer's disease is a progressive neurological disorder with overlapping psychiatric symptoms. Alzheimer's disease is a progressive deterioration of the brain. The brain regulates behavior and personality. In our society we have severe bias and prejudice toward mental illness and pass judgment harshly on psychiatric disorders but not neurological disorders." That's how I would answer that right now. There just is not a perfect yes or no answer. The correct answer is both, the more correct answer is, it does not matter, If you say yes it is a mental illness, you would not be incorrect but it immediately changes our views of the disease, based on our biases. If you say NO it is not a mental illness, we all breath a sigh of relief. We feel a bit better in that disease is legitimate.

In the end the question does become irrelevant as you or your family member struggles with the diabolical process. It does not really make the process easier to know it is not a mental illness.

Remember people with mental illness are just people, they have feelings too, hopes, dreams, just like everyone else. People with mental illness can develop Alzheimer's disease, just like people who never had mental illness can also get Alzheimer's. The behavior and personality changes associated with Alzheimer's can be at times crazy, bizarre, strange weird, it is upsetting and disquieting. The person is not doing it on purpose, It is not a sign of character, or something we have done right or wrong in our lives. The same can be said for mental illness.

The health care world incidentally and ironically has some of the strongest and worst biases about mental illness. As a psychiatrist, I face it from other doctors, maybe not as much as from other non-physicians that work in the health care field, but it is there. There are also so many people in the Alzheimer's world- caregivers, health care workers, bureaucrats, that have this bias, it is so Hypocritical, two-faced and not very humane, but it is where we are at as a society. Something we don't like to talk about or admit, Alzheimer's=neurological, mental illness= uncomfortable, "icky". Let's admit that prejudice and start growing up and working past it.

Until we start getting over ourselves and becoming truly humane towards all disease states, and people suffering from them, including mental illness, you are not going to see much true progress. towards treating the aging population with respect, dignity and honor. After all if it is easy to secretly judge people with mental illness, it is not easy for the fascist, intellectual, politically superior to exploit this?- to place less value on the aging and the elderly and those with Alzheimer's disease? Get it? We are talking out of both sides of our mouth when we distinguish Alzheimer's as not a mental illness. It is easy to exploit that paradox, that is part of the reason why we have not advanced much in our society in our understanding of Alzheimer's, and we ponder the question of AD being a mental illness. It is a vicious circle. Throw in the health care debacle and limited resources, and you are one step away from the E word, euthanasia.
Hence cost savings- euthanasia. free thinking atheist, cool people with certain correct, political views= forward thinking know- it-alls? utilitarian,- grow up.- most people will get old some day, and all that youth driven narcissism won't really matter will it? "How many people under thirty years old, say "well if I ever get like that just shoot me!"
It's all our faults, it's how we are raising up our kids, generation after generation.

Here is an a paradoxical, optimistic point, I believe the legitimacy of AD will be hammered in stone (in other words the clinical world will catch up to the research world, and we will have everyday access to the legitimizing tests that unequivocally convince us that AD is a clinical disease) this will happen long before the stigma and prejudice toward mental illness is obsolete.

If I was a policy maker, or if I worked for a nice big non-profit and could lobby for AD all day, I would lobby that the question of Alzheimer's disease being a mental illness is irrelevant. I wouldn't spend all day working to draw that line ion the sand, that distinction for society. It Exacerbates the stigma, to argue the point.

So my mother's Alzheimer's disease was a factor probably in me going into psychiatry, but not THE factor. There was no one main factor. It certainly taught me about empathy, and emotional pain and loneliness, ands societal prejudice, something most psych patients deal with on a day to day basis. (and family members of an Ad victim.) Yes its true I saw the emotional anguish the disease causes, I lived it. I thought psychiatry was the most humane of all medical specialties, some days I still think that, other days not. After all, a psychiatrist talks to their patients, understands there patients from a human aspect, not a disease aspect, or so most of us thought. That is why most went into it. It seemed to bridge the gap between the art and the science of medicine in so many ways, in ways that nobody cares about much anymore, in ways society places little value on- IE. humanity. Cost-effectiveness supersedes humanity. that's the reality, throw in some power-drive economics and political correctness and well you have more bias and prejudice but yet we still convince ourselves everything is okay.

ELECTRONIC PRESCRIBING

2010-08-13T00:57:00.000-07:00

hmmmm call me old fashioned, call me a heretic. But will this really improve care? If I was one of those slick high tech cool medical bloggers, I would tell you how wonderful it is and how the art and the science of medicine will be so greatly advanced and how much this is going to help patients. Lots of people would read and retweet, the news media loves it and it will help patients.
Now lets talk about the realities nobody wants to blog about except me it seems.
First of all, how will it help patients. LESS ERRORS. This is good. How so? Handwriting errors, handwriting errors HANDWRITING ERRORS. Fantastic. Hmm is that an N or an H? I can't read the handwriting. EXCELLENT. No more of that ever. IT will probably save a few lives every year.
Think about it there are only so many ways for a prescription to get from your doctor to the Walgreen's in your neighborhood. 3 ways actually. The doctor phones it in to the pharmacy, the doctor faxes it to the pharmacy, or the doctor hands you a handwritten prescription to take down and hand to Kristen or Eli your ever pleasant pharmacy technician at the drugstore.
That's it that's how it works. No More. Electronic prescribing will be the law in the great progressive State of Minnesota at the end of 2010.
It will cut down on other errors too. Maybe. Theoretically You can have a more thorough list off all the meds you have ever been on. This should help on missed drug-drug interactions. Right. Sounds good.
Hows it work?
Well first off all most people that work in medicine are not doctors, they could never see electronic prescribing as being anything but good. These non medical people actually write most of the templates for the software for electronic prescribing. Big money to be made for these non medical- medical consultant experts. Licking their chops so to speak.
So you doctors office or somebody spends a lot of money to get the templates and then they can electronically prescribe. It gets sent to the pharmacy electronically, sort of to a clearing house over the Internet, I guess you could call it sort of an intranet, and it is about as secure as secure can be with lots of firewalls and things. I mean think about how secure your stored information is when you purchase something over the Internet. nice and secure, nobody could ever get in with all those firewalls.
The software really is great, lots of drop down menus invented by non-physicians telling you exactly when where how much how often you get to prescribe something. Since these templates are generally written by non-medical people the art of medicine really shines. You doctor can't really personalize the treatment to you.It is rigidly standardized. Sure there is a little place at the end where you can attempt to put in specific instructions, often hard for the [pharmacist to find and extremely user UNfriendly for the doctor, to actually individualize the treatment to the patient. I mean we all fit into nice pigeon holes, right?
Then there is the issue of the fact that many non-physicians are going to be entering the prescription into the computer and hitting "send". Boy I hope they are not having a bad day or pissed off or something or having a bad home life that week and don't make an error on the drop down menus. Its ok though because it will still be the doctors fault in the end.
Then there is the beauty of the fact that depending on the software and the clearing house, something you took for a week will still be showing up years later, like you broke you toe and went to the ER and got three lortabbs. That just will keep coming up or or you took amoxicillan for a strep throat five years ago for am week. Right there in your face, the dates and quantity may be a little less harder to find. Sort of got to look. Hopefully someone will mark it as not active but expired stuff still follows you around, thank you rich thoughtful computer software companies medical non-doctor consultants.
But here's the best part. Formulary restrictions, all a patients data is out there including insurance, behind lots of firewall encrypted safety devices of course.
In other words when a doctor tries to prescribe something and a patients insurance won't cover the med-BAM the clearing house will reject it. Nice hunh? You are not allowed to have that med. It is like that now, but at least we still have the old prior authorization,- that's where you doctor spends all day usually several, fighting with some private sector company employee of a corporation contracted with the federal government, sitting in some cubical in Solon or somewhere telling the doctor they are not allowed to prescribe the appropriate med and to use something else.
It will be a lot easy to avoid this, with e-prescribing and to really really start limiting and putting the clamps down on what meds you are allowed to have based on your payer.
And this part is even better than best-now we can truly monitor physicians prescribing habits and make lots of inferences and punitive actions against physicians who prescribe too many expensive meds. Way to really reign em in. Bout time right? Unless its your husband or wife. then shouldn't they have the best medication even if it is expensive? Nope and NOPE.
Anyways I guess it will cut down on forgery and prescription drug abuse too right? Maybe. Luckily criminals are not smart with computers and all that stored information on you and dangerous drugs out there in the electronic password encrypted firewall protected cyber world.
Call me old fashioned, I will get used to it. I must be getting old and set in my ways, I just don't think human beings and their treatment fit into drop down boxes and templates. It will be OK though, in all fairness a majority of hospitals have been using electronic entry of orders and meds for inpatient units for years. Why look how often we don;t have errors in those hospitals anymore.
Pretty soon we can have a robot hold your hand or talk to you instead of a human, technology-nice and healing but a human will still have to program and turn on the robot, chances are it won;t be a physician.
In more all fairness the Government Medicine Programs the VA and the DOJ (Federal Prisons) have excellent electronic prescribing and electronic records, that are prototypes and lead the way. I'm sure we can find lots of data on how errors have been decreased and patients helped and the care improved over at those venues. Right?
I know I got to do it. It just feels sort of bad to have something imposed on you, when you had a pretty good system and checks and balances set up to avoid errors, and now you have to change, you had something that worked and maybe the system you had actually helped patients and not hurt them, and now that system will be illegal in a few months. Sad Sad Sad.
By the way do you know how often I hear- "the doctor (half the time it is a nurse practitioner) never looked at me they just kept staring at the computer screen"
and here's a good one "the doctor could not do anything, the server was down, they were having trouble with the computer"
I hear those quotes a lot more and more every year, I pray those are not said about me someday.
A final thought, I think we should be more cognizant of the CEO' salaries of these medical software companies and start scanning the benevolence factor of these companies- kind of like we do the drug companies, God knows there first priority is helping the patient.

On medical blogging

2010-08-07T12:03:00.000-07:00

I read so many blogs from doctors, the psychiatry ones like to discuss how psychiatry has been reduced to simply writing prescriptions. It is old news. Most psychiatrists did not go into psych to write scripts all day to see patients every ten minutes. Generally speaking most start out with the ideal of wanting to understand and help their fellow human being. Old news.
Then their are the usual blogs about bashing the pharmaceutical industry, nothing new, usual stuff, politically correct. Meds are bad, pharmaceutical companies sinister etc etc. Lots of bad doctors pandering to the drug companies. People love these blogs, safe politically correct targets to bash.
There seems to be more physicians blogging than ever before, but they may reflect more the fact that there are more people blogging than ever. Some are a bit more pithy than others, some walk a political line, hoping to stay ahead of things with electronic media preserving their place in the cosmos, as the current physician-patient relationship, the therapeutic alliance, what medicine was created on since the beginning of human-kind, continues to erode. It erodes because of economics and politics.
I hate it when some of these blogs stay on the right side of the line, stopping short of speaking what is really on their mind. You can feel it and smell it. They don't always speak with candor, they may be honest, but they don't say what people don't want to hear, because nobody would read them. Fortunately for the blogger it is a world where most people are on the outside looking in, so most would not know if they are candid or not.
The blogger feels good because they are honest, but generally there is a pervasive fear and a general need for self-preservation, that behooves the medical blogger to stop short of telling the whole story.
Some actually open up about their human side of things, but one must be very careful with that. It is a very ultra thin line as we still hold the medical profession in some sort of bizarre precarious inflated esteem.
We want and assume our doctors to be smart and flawless and the greatest healers, but we know and expect them to be money-grubbing, selfish crooks, who don't care about their patient. We almost expect it, and the system reinforces our negative perceptions. We look and wait for any clue to reinforce it. Is it any wonder the most prolific medical bloggers stay on the safe side? What option to physicians have?
I always assumed that the physician was the primo patient advocate, but nowadays we must be wise consumers who bring people to advocate for the patient against the physician. Who truly made the system adversarial? FDR? LBJ? Managed Care? HMO's? the AMA?
Perhaps I idealize the past, maybe the system was always adversarial, maybe the old physician-patient alliance was always challenged and precarious. I have to admit though since I have been working for 17 or 18 years now, it seems that their is less and less opportunity to take care of your patient and much more paperwork, defensive work, fighting with insurance companies and so many things in the way of letting you care for your patient. That part I can see. The doctor is just not free to practice medicine anymore. Yet on some level in the end, we still want our doctor to be the best and do everything right.

Man-Cure

2010-08-01T16:57:00.000-07:00

I have found a rather odd way to connect with my dad over the last month or so, I have started trimming his fingernails. And man, they do grow fast. At first he was really apprehensive about me doing it but has become OK with the idea. Today I trimmed his fingernails and toenails. It's really good for me and I think for him because when I am concentrating on it, it is something tangible I can do for him. It also distracts him and seems to calm him down. So instead of a manicure, I'm gonna call it a "Man-Cure."

His dementia is getting worse by my estimation though Dr. Sivak says these things ebb and flow and progress slowly over time. I get that but he's beginning to check out on us a little more. Ironically, his "worsening" has made it easier for me to visit him because he has forgotten, for the most part, that he was angry at me (for moving him out of his home). I have had 4 or 5 consecutive visits without him getting ugly or aggressive. It is such a huge relief. My 3 year old daughter and I visited today. We also visited last Sunday. Dad still knows me and her and we are thankful for that. He cannot read anymore and there are many words and things I mention that confuse him and I am having an increasingly hard time understanding what he is trying to say. Today I mentioned I had driven one of his classic cars, his 57' Chevy. He had no clue what it was, at all. The week before I showed him a picture of the Chevy, that he could connect with that but not the uttered words. When it comes to an emotional connection, that is still 100% there. He laughs and smiles and has a superb time with my daughter.

I have finished reading Dr. Sivak's book. It was wonderful, I plan to write a full review sometime soon. Thanks be to God. JP

Elder Rage Review

2010-08-01T11:03:00.000-07:00

Here is a review I posted on Amazon for Elder Rage, Jacqueline Marcell's book about her struggle with her father's Alzheimer's:

-"As a Physician and a Caregiver for my mother diagnosed with Alzheimer's when I was a teen, I recommend this book to caregivers. Not only do I advise this book to be read by caregivers but by the general public at large. Alzheimer's is something we don't want to know about or hear about till it touches our own family. It's time we open our eyes. The book is thorough, gripping, and filled with insights that offer utility to caregivers of AD victims. No matter what age you are when a parent or loved one is affected, AD is a coming of age process. It makes people grow up, and dig down inside ones' spirit to find the courage to persevere. Jacqueline did something with this courage and fortitude and offers it to others in similar circumstance. I had the pleasure of appearing on the Author's Radio Show "Coping With Caregiving", and found her to be gracious and a Caregiver Advocate, filled with passion and zeal toward bringing this disease out of the darkness. It is a passion and insight that I rarely see in regard to this devastating"-
Joseph J. Sivak MD

Alzheimer's Research

2010-07-25T11:22:00.000-07:00

So it appears the thrust of research at the recent consortium is to take all the research that has gone on at various facilities and share and combine and put something together meaningful. The criteria for diagnosing and staging Alzheimer's and mild cognitive impairment is being reevaluated for the first time in years. When you think about it, this is crucial. There has been a certain way of diagnosing the disease definitely by looking at microscopic tissue under a microscope. That has not changed and we still can't do that on live human beings. However if there was a way to predict or even diagnose the disease much earlier, even before it starts to clinically show itself and manifest, this may have clinical implications for treatment, as well as prevention. Seemingly the earlier you can intervene or even prevent the better.
Hence emerges the concept of biomarkers. This is not a new phenomenon. The biomarkers we are talking about are more than testing for the genes that definitely predict who will get the disease.
The well known presenilin and APOE genes. The hereditary links are somewhat better understood, however the overall genetics are still not clear. There are very rare instances where there is a direct hereditary link, which account for a small number of AD cases, relative to all the cases.
But what about the vast majority of AD. Emerge biomarkers.
There are a couple that can be evaluated looking at CSF. CSF is cerebrospinal fluid. This is the fluid that baths the brain it runs down throughout the spinal cord. It is in the ventricles of the brain, Everyone has it.
Most people have heard of an LP or lumbar puncture or spinal tap.
A spinal tap is most commonly known as a diagnostic intervention for example when it is suspected that a person has meningitis. That is an inflamation of the tissues covering the brain and spinal cord. The CSF is sort of a purified version of fluid sort of like plasma but different. Sometimes you get an infection in there and you can look at the fluid , sort of like a blood test. You get the fluid through a needle in a spinal tap. Now meningitis or infection like that has nothing to do with AD. however you can do this spinal tap and look at fluid and analyze it, like a blood test.
It does appear people with Alzheimer;s have some proteins and chemicals in the spinal fluid which would be changed and possibly a good marker for AD. Hence the biomarkers. It is possible some of these protein fragments are related to the Amyloid the develops in the brain of AD patients. now it may also be possible that these molecules that are too high or low in the CSF, indicative of AD, show up maybe much earlier than the cognitive and behavioral changes of AD. Not really totally clearly understood, but getting there.
Hence the consideration of new diagnostic criteria, and maybe someday the analysis of these biomarkers being used not in research but in everyday clinical practice.
Getting somebody to pay for this testing on an everyday basis is another story. Remember, since AD is fatal and it affects mostly older adults it is not a politically or economically popular thing to fund.
If some of this testing ever becomes more mainstream, it will be new cutting edge and therefore expensive. sort of like when a new electronic computer or phone type thing comes out.
but it is crucial because I think the research is on to something, we really have been trying to understand and treat or prevent it, once it is so full blown and that is probably way to late.
The research is fragmented, it does need to come together and share ideas, I still think it is misguided and stupid to have meetings in such elaborate places as Hawaii, but we somehow have to bring people together. The greatest minds working on this stuff. Remember in research, there is a ton of collaboration and collegiality. There is also a ton of competition. People fighting for grant money, for recognition, for the first to be published on something. Research has always been that way. It is just human beings. The motivations between altruism and notoriety get sometimes blurred. Again something very real but taboo to discuss.
Some key thinking and thinkers coming together happened.
With the asinine health care climate in the everyday world, I hope and pray some of the forward thinker of the greatest research minds will trickle down to everyday mainstream clinical practice, and suffering families, who really don't give a damn about who gets published first, or the terrbile health care climate, they just want hope and treatments, preventions and cures.

Home Care News > Connecting the Dots: Coping with Alzheimer's Disease

2010-07-20T12:17:00.000-07:00

Home Care News > Connecting the Dots: Coping with Alzheimer's Disease

enjoy.

God Bless,

Joe

Book Signing-Florida

2010-07-19T12:52:00.000-07:00

The book signing in June in Florida went well. I did a talk about Alzheimer's and the book and my perspectives as a caregiver at age 17 to my mother as well as a couple readings. There were some wonderful questions, and I have to say the issues and struggles people are dealing with for their loved ones have not changed in 30 years, since I went through it.
I want to thank the staff at Lake City, Orlando, and Ft. Lauderdale public libraries for hosting these events. They were gracious hosts, the presentations free of charge and were just for anyone interested in AD. Most people as you know are not interested in hearing about the disease till it touches them.
People are looking for answers, validation, reassurance, and new meaningful information. Very caring family members, good folks, regular human beings just trying to do the best they can in the face of this devastating disease. There are so many unique and touching stories out there in families, about a human being their loved one. Their loved ones are so special, the pain and suffering is so humanly universal.
Here's some photos from the events.

Ft. Lauderdale

Lake City

Orlando

If you want to pick up the book, heres a bunch of links where you can get it. you can also ask your local library to order it, or your local book store.

You can get it online at the Publisher- Niagara Press

Niagara Press

Or Amazon

Amazon

Or Barnes and Noble

Barnes and Noble

ICAD- huge meeting in Honolulu this past week

2010-07-17T15:41:00.000-07:00

Well the Alzheimer's Association held its international conference this past week in Hawaii. A beautiful place for a conference I might add. Some from the NIA was there and if you were a member of ISTAART you got a savings off the price of the conference. If you went and actually had to pay for yourself the conference alone would have cost about $800 dollars. I'm not sure about everyone else but if you had to pay for your own flight, that for example would set me back about another $900. Throw in another $800 or so for room at the Official housing of either the Hilton Hawaiian Village Beech Resort and Spa or the Sheraton Waikiki. well you get the picture if you paid for yourself to go $2500-$3000. Hopefully if you went your institution, public or private paid for you. There are also plenty of grants and rates I'm sure. It was attended by thousands. My God where does all this money come from? For some perspective, a year of Aricept, (I know it only helps a little for some and we need better meds) costs about $2000 a year. now the average cost of a home health nurses aid, that is someone to help give the family member primary caregiver a break is about $21 an hour. so at three hours a day, five days a week, that would be about $2400 for two months of home care at three hours daily.
Now from the preliminary info at least reported by Netscape, there were lots of expert work-groups. I am sorry to say that there was no cure, new actual meaningful treatment, or a 100% definitive way to diagnose the disease that was brought forth. Believe me if there was, you would be the first to know. There were lots of interesting things, a revision of our understanding of MCI, and our conceptualization of Alzheimer's, probable Alzheimer's and various other things, I will tell you about in days to come. But in the end, lots of excitement, and chatter and idea exchanging and of course networking. If you are a caregiver, nothing that is going to change you life and least in the near or intermediate future.As a physician, from what I can see, nothing truly new, lots of classification of things that will trickle down to the clinical world over the months and years, but again nothing to practical for the day to day caregiver. New data on vitamin D and anti-oxidents, (remember when the experts met a few months ago and said there was nothing new in this realm, well maybe there is.
an exciting motorcycle Rally coming up in which researchers with Harley's, (I'm assuming they are Harley's, hmmm I don't have one but I think those set you back about 40-50K) will be riding across the country to raise awareness for research and get signatures for a petition to congress to get the ball rolling on research. It sounds fun and worthy, if I could go, I couldn't anyway, cause all I have is a car. I'm am sure you will be hearing more about this motorcycle ride It starts today in San Frnacisco and culminates on the steps of congress and National Alzheimer's Awareness Day in September, where the signatures will be presented. If you are fortunate enough to have a Harley and be one of the 65 riders, well it sounds like fun.
In all fairness I did not attend the conference, I can only report and translate to you the reports I read. You will find hundreds of twitters about all this over the months, national media stories, false hopes on new breakthroughs (not there yet), and plenty of publications in the scientific journals going on lots of CV's. I think if I had attended, the honest to God truth is it would have been hard for me to stay in the conference all day and learn something. I mean come on Hawaii for God's sake? That is like the most beautiful perfect weather place in the world. I'll keep you posted in future posts on all the conference proceedings I read.
I know it seems like a disconnect, you are all doing the best you can in the day to day grind, caring for your loved ones, or visiting them in the Nursing Home. Some days it is awful and you hate it, and you ask why. take breaks, I know it is emotionally devastating, as well as financially for many of you. Hang in there.
Next years meeting is in Paris by the Way. (THE Paris you know- Eiffel tower and stuff).

Addendum- (I think rooms and Airfare to Newark are cheaper and they got plenty of space for meetings for thousands of people, same with Omaha by the way.)

All kinds of caregivers- a very thankless job, and Health Care Reform Digressions

2010-07-09T00:56:00.000-07:00

So much of this blog is about the caregiver, that is the family member, caring for a loved one with AD. I try to cover some of the plight of those in this blog, having been one myself at a very unproven age. I also spend a lot of time trying to cover the plight of the physician, having been one myself for all my adult life. Lets face it the odds of building any empathy for the doctor, are about nil, it can't be done, and lets face it with our wonderful sweeping health care reform the odds of seeing the doctor in any sort of possible non0negative light will be even less. I mean come on, as the oil gushes out after months, as we all dip into our 401ks a little more, if anyone has anything left in them, has not your health care and access already dramatically improved??? Digression.
Lets face it, After all the banks merge, all the airlines merge, We can have a state run bank, a state run airline and maybe if we are lucky a couple huge health care "private"corporations, heavily vying for that big old capitated national government contract, low-bidding each other every year. Think about it, that's where it is going. -Digression
So what about all those other caregivers, the RN's, the LPNs, the CNA's, the home health agencies. the MSW's, the speech pathologists, the BSW's, the PT's the OT's. I mean my God they work with an awful lot of dementia patients don't they? We forget they tend to get a little emotionally beat up by families of dementia patient"sometimes, they get attached to some patients, they thrive and love it when their AD patient has a "window" or a good day just like the family members.
Families often get mad or short tempered with all of these other caregivers, trying to do the best they can. Why is that? They don't have the history. They don't know Mom or Dad, like the family. How could they possibly know? Sometimes it breeds indignity, or anger. Its the nature of the disease.
Most go into the helping professions, to help people. We go into it, wide eyed and idealistic. Little secret, most people doing it a few years that give their all, really want to get out of the game. Most don't admit it to themselves, but administration, looks pretty damn good after a few years. Working hard in this field giving your all, sort of robs you of part of your soul, it takes its toll to be a caregiver. Especially the ones who care.
Think about it less people want to take care of patients in this day and age. The pay sucks relative to the time and effort you put in and the things you give up. Less people going into primary care, the numbers going into psychiatry, is like a joke it is so minuscule, relative to the need. Many people going into nursing, don't want to take care of patients, the thought of getting dressed up and walking around a big old health care facility with beautiful atriums, carrying a clipboard, and going to important committee meetings all day is much more appealing, than say getting slugged by a patient with dementia while trying to give them a bath.
Yep for the true caregivers it is often a thankless job. But most of them do care. A lot.

Lack of reality leads to a reality check

2010-06-29T13:01:00.000-07:00

Over the last few weeks have had these thoughts that if my father (dad has dementia/alzheimers) passed away before my mother that we might be able to bring my mother home to live with us, finish out our basement, etc. I understand that this is just the hope-full part of me that wants to hang on to some thought of renewal or future. But then reality of my mother's condition hits me square in the face. We attempted to take my mother out to eat with all of her grandchildren this past week. The plan was to take her out of the memory care facility, go to lunch, come back and then visit with my dad. But, my mother threw a fit, and could not understand why we could not also take my dad. I told my mom that we could not because of his dementia/behavior. She then flatly denied that my father had dementia or alzheimers. Mom basically has lost touch with reality. The LCSW that works with us has been telling me all along that mom's reality checking or degree of reality contact is just not there. Unfortunately it is true. That combined with her history of RX drug addiction, personality issues, depression and anxiety, will most likely make it impossible for her to ever live alone again. It's just a sad reality. My mother might not have dementia but in many ways she is just as sick as my father.

So, that is the story of how my mother (who I love so) has lost touch with reality and at the same time given her son a reality check.

More on Medicine and agitation and Dementia

2010-06-28T20:25:00.000-07:00

Alzheimer's disease affects the brain. It destroys brain cells. Loosing ones memory and the ability to reason is the hallmark of Alzheimer's disease. The brain whether we like it or not also regulates emotion and behavior. Essentially our ability to feel starts with the brain. One of the hardest and scariest parts of the whole process, (besides everything else) is the behavioral changes. A person with AD, can begin to behave in very strange and uncharacteristic fashions for themselves. It is bizarre and frightening quite often for family members. As the disease wears on the person with AD looses their ability to self-reflect-to have insight into their own behavior. It is not their fault and if they could they would hate it more than you do- but they can't.
It is also unique in that one day for no apparent reason the behavior can appear quite normal and baseline and it seems everything will be okay. The next day the behavior is strange, odd, bizarre, frightening, maybe hostile, maybe threatening. It is enough to drive a family member or loved one nuts. Yet the AD victim can't help it.
Hence emerges modern medicine. "Why can't the doctor do something?" "Help them doc!"
Keep in mind to this date yours and my Federal Government and its regulating body the FDA The Food and Drug Administration has approved no medication specifically for the treatment of agitation in Alzheimer's disease. Yet in modern society we use meds all the time.
Now I don't want to get all that hate mail, thinking I am pro-meds, "pill-pusher" "doctor does not take the time" "how can they just throw meds at my mother or father, they don't even know him or her" -I know. Believe me I am not pro-meds, I just happen to know the pragmatic realities, expectations and limitations of them because that's what I was trained in. I would rather see anything and everything that can be done other than meds to help the behavior to be more balanced and normal for that person. As family members know, simple reasoning does not always work with the AD victim. -It is not their fault.
As far as the specific meds, sometimes the cholinesterase inhibitors the Aricepts of the world can help the behavior, sometimes they can actually make it worse.
The are indicated for AD not specifically for the behavior.
Sometimes the antidepressants can help the agitation the Zolofts of the world and sometimes they can make it worse. A person with AD can be depressed, but they can't necessarily tell you. But even if you can't make a clear diagnosis of depression sometimes the antidepressants help agitation. I talked about the atypical antipsychotics in the past. the risperidones of the world. Sometimes they help, sometimes a lot, the government and medicare are all over this with warnings about increased risk of stroke in psychosis with dementia, and the omnipresent diabetes risks.
the benzodiazepines, the Ativan's of the world sometimes help, and sometimes they disinhibit and make the person worse. They are cheap, addicting-not always a worry in dementia patients, and the primary care world loves them.
Then there are the Antiepileptic meds, the Depakotes of the world. Sometimes they can help a lot in low dose, but they can also cause worsening effects with sedation for example.
It is often a balance of calming the behavior without sedating the patient too much. Sedation seems to aggravate the already declining cognition and ability to think.
Ask what your doctor is prescribing and why. If you think your loved one needs meds for agitated behavior, ask the doc which med and why.
Low and slow is the key. It is an art and a science. It takes a little finesse and knowledge base, and in medicine that like anything else is variable. The meds are not going to work miracles, and your doc is probably not stupid or holding out in the best med for some ulterior motive. They are probably adequate and average at least. But if you don't trust her or him, then get another one. If you are only allowed to see a mid-level prescriber, such as a nurse practitioner or a physician assistant, and you would rather have your loved one see someone who went to medical school and had years of residency training then ask for one.
Remember the agitation is not the AD victims fault. Think of the brain as a stoplight at a major intersection 12 lane intersection. Then a storm wipes out the power. Everyone has to get to work. There is always the asshole who runs through the intersection, and then many more who are uncertain or scared to proceed. It is chaotic.
If you ever rented a truck, say from Penske or U-Haul they have a governor on the engine, you can't go past 65, conversely it may be tough to get up a hill. The brain is the governor of behavior. AD is the storm that wipes out the traffic light, AD removes the governor on the truck and you got a run away truck. It is not the victims fault.

Radio Show "Coping With Caregiving"

2010-06-25T14:21:00.000-07:00

I will be in the internet radio show
"Coping With Caregiving" Saturday 3:15 pacific. 6:15 Eastern. The show is hosted by Jacqueline Marcel whose father had Alzheimer's. she wrote a book about it called "Elder Rage."which you can find a link to at the radio show site.
Here is a list of the guests
JUNE 26, 2010 3-4 PM PACIFIC TIME:
Bill Dyess (Gelbwaks, Long Term Care Insurance),
Joe Sivak, MD ('When Can I Go Home?'),
Carolyn Rosenblatt ('The Boomer's Guide to Aging Parents'),
Chris Tatevosian ('Life Interrupted: It's Not All About Me').
click on the link and follow the directions which are pretty straight- forward Radio Show

On Being a Psychiatrist

2010-06-23T21:47:00.000-07:00

Here is a little story I wrote, depicting some musings on being a psychiatrist. I wrote it a couple years ago, for a Minnesota Medical Association little writing contest. They did not see it as a winner and therefore not fit to print. If you still wear Birkenstocks, raise Llamas, vote a certain way, and present a certain, non-disquieting view of medical practice, well that may make for a better and potential printable winner, so that rules me out. We do like our realities to be in a certain way up here. The stuff we know: we know The stuff we don't know: does not exist. Its mostly the stuff we don't want to know: does that exist?

"ON BEING A PSYCHIATRIST"

Joseph J. Sivak MD

"The shiny brown leather couch glistens in the late afternoon sunlight. The couch envelops the supine patient. A bespectacled gray-bearded man in a brown herringbone tweed three-piece suit sits in a cherry-spooled rocking chair a few feet behind the patient, frantically taking notes. The psychiatrist directs the patient, “Tell me how you feel about that.”

The patient a perpetually shy woman of about forty years shifts on the couch and obsessively twirls her pearl necklace and chews on the white beads, as a grandfather clock on the other side of the room seems to tick more loudly than ever. The patient struggles with her analysis. The psychiatrist pulls out a gold-chained pocket watch from his vest. “Hmm…times up for today. See you tomorrow at four.”

The patient hastily rises from the couch, walks out of the room and pays her bill to the receptionist, handing her cash from her purse. It is a bill for services to have ones head shrunk, to become actualized.

This archetypal image has little resemblance to the modern day twenty first century practice of psychiatry. Hollywood holds dearly to this quintessential image, as does a vast portion of society. It is a romantic, classic, yet profoundly irrelevant image. In fact I don’t even have a couch in my office, let alone a grandfather clock. I do own a three-piece suit somewhere, but have not worn it since the eighties.

The patient scowls across the room at the harried doctor. The doctor has fifteen minutes with the patient and unfortunately has three people waiting in the crowded waiting room and he is already 45 minutes behind. The patient barks, “You better give me some klonopin or adderall dude, cause if you don’t, I don’t know what’s gonna happen. I might violate my probation and I’m not going back to prison. I’m gonna hurt somebody if you don’t give it to me dude.” The patient is agitated and twirls the chain on his wallet in one hand and beats a cell phone against his leg with the other. The psychiatrist hears someone in the waiting room loudly swearing at the receptionist for having to wait so long.

This scene may be somewhat more realistic for many modern day psychiatrists, but not as classically romantic as Hollywood wishes for. When I was in medical school and I chose a residency in psychiatry, I still held on to a bit of the classic archetypal image. The image implied that the patient actually wanted to be there, and happily paid their bill. I liked the idea where the patient developed new insights into their unconscious and became healthier. The idea that almost everything had a meaning and was precisely interpreted was most appealing.

Many myths and misnomers abound in regard to the modern day practice of psychiatry. Many people believe that psychiatrists are extremely wealthy. They stare in disbelief during conversation, when I advise them that psychiatry is the second lowest paid specialty in medicine. They are shocked when I advise them that most medical students don’t choose a residency in psychiatry because there is relatively little pay compared to other specialties. They are dumbfounded when I advise them that 90% of my patients don’t pay in cash or check or credit card and that the vast majority of my patients don’t pay anything at all for their psychiatric care. It seems that it is much simpler to hold on to the classic romantic view of psychiatry.

Another popularly held myth is that most psychiatrists are a bit crazy and simply go into psychiatry to figure themselves out. Sometimes I ascribe to that view, but I can honestly say that the rate of craziness is probably not any higher in the field, than say surgery, or the legal world or carpentry or any other line of work. The psychiatrist just hangs around professed psychopathology all day. But you can’t really catch mental illness per say in the same way you catch a cold. Most psychiatrists are actually rather humane, empathic individuals that chose the profession because they were interested in truly helping their fellow human being.

Ideally, in medical school, I felt psychiatry may have bridged the gap between the art and the science of medicine. It starts at an infinitely tiny point, namely the human brain and explodes into every scholarly domain. It touches philosophy, sociology, art, history, biology, chemistry, anthropology, linguistics and psychology to name a few.

After practicing for fifteen years, it is so very different from what I idealized back when three piece suits where still in style. The pressure like most areas of medicine nowadays can be ungodly. Idiosyncratic pressures in the field are abundant. For example psychiatry is the only field where one might be sued for malpractice, for failing to protect someone you never knew existed. Depending on circumstance, the psychiatrist may be held liable if their patient harms someone else. The degree of violence in society is astounding and dictates the scope of many psychiatric practices in America today. Violence often stems directly from early abuse and neglect and a lack of human regard and connectedness. A large percentage of my patients grew up around violence and abuse with very little familial nurturance. Simply having no other option, be it determined by nurture or nature, they continue to perpetuate the cycle and are often predisposed to anger and impulse problems. Unfortunately for some the psychiatrist often becomes the displaced object of that anger. Every year in this country a significant number of psychiatrists are assaulted and one or two actually murdered by their patients. The threat rivals that of a busy emergency department, but the psychiatrist’s office is usually not equipped with armed security, unlike a busy intercity ED.

It is often common for a patient to visit a psychiatrist’s office for some reason other than coming to get treatment for an illness. This was something never taught much in training. Reasons range from: staying out of jail, to getting ones children back from social services, to getting disability income, to improving their divorce outcome, or to keep their job. Often when there is some primary reason for being there other than getting treatment, the person may feel everyone else, including the psychiatrist has a problem. Pulling the psychiatrist out of the role of physician and into a role of manipulating ones social environment can often have little to do with true patient advocacy or treating ones mental illness and making the patient healthier.

Another strongly ascribed to fallacy is that psychiatrists are all just “pill-pushers”. The truth of the matter is that most medications can and do eliminate psychiatric symptoms and alleviate suffering, but in 2008 most medications do not essentially cure or heal mental illness. There are fascinating breakthroughs in the understanding of the plasticity of the human brain and discoveries of such substances as brain derived neurotropic factor. The mapping of the human genome also has profound implications for psychiatry, but we are still hard pressed to prescribe a medication that heals psychological wounds and cures psychopathology. Yet in our fast–food, Madison Avenue Based society there is much pressure and unrealistic expectation to simply prescribe a “happy pill” or a “normal pill”.

At this point in time till proven otherwise, the healing component directly relates to and takes place in the relationship between the patient and the doctor. The psychiatrist often becomes the only safe and stabilizing figure in a patient’s otherwise chaotic, entropic life. The doctor often becomes a nonjudgmental empathic entity that the patient can depend upon. In this sense there is almost a re-parenting process that takes place, in the transformation towards psychological healing. Indeed some strictly biological psychiatrists would scoff at this idea, while at the other end of the spectrum non-physician psychotherapists often believe that the psychiatrist does not even talk to their patient in lieu of simply pulling out the prescription pad and begin scribbling on it. Most good psychiatrists, the ones that actually take care of patients all day know better. The medication prescription often takes on more than biological implications. It takes on metaphorical proportions as a symbol of the most ancient of archetypes the physician patient relationship and the healing that takes place.

The ultimate loss of a patient comes in the form of suicide. When a patient walks out the door of the office, the doctor can never be 100% certain that a patient will be safe from harming themselves. Even when the psychiatrist does everything within their clinical capabilities, they can not always save a patient from themselves. This is in the context that depending on the practice, a psychiatrist may treat hundreds if not thousands of patients a year who are chronically suicidal.

The academic challenge can be more elusive. It is true that there is little that surprises or necessarily intrigues me about human behavior anymore. Another Hollywood misnomer is that the average psychiatrist finds human psychological aberrations so very interesting. Indeed at a dinner party when the conversation turns to some strange behavior in someone’s uncle, all eyes turn to the psychiatrist for a response filled with alacrity to hear more. I suspect this is true for the psychiatrist that sees three patients a week. Most see many more. Many psychiatrists would rather discuss baseball or Beethoven or bookstores when away from work.

It is true that I have heard tens of thousands of narrative life stories filled with anguish, terror and pain, and after one or two pieces of information I can usually fill in the rest quite accurately in the narrative. This can lead to a cynical attitude in the psychiatrist, or conversely it can be used as a gift to help patients feel cared about and understood. The understanding comes from a perception of an uncanny clairvoyance on the part of the doctor and empathy for the patient by making the patient feel that their story is unique. When they are sitting in the office, their life story is the only thing that matters to the doctor.

Over the years it has also become apparent to me that the mentally ill can not always speak for themselves or stand up for themselves. The current health care climate continues to perpetuate this phenomenon. There is a greater responsibility than ever for the psychiatrist to advocate and help fight the stigma of mental illness. This can only help each of our individual patients that struggle with these issues.

So from that ideal image I conjured up almost 20 years ago to today, my perceptions have changed a bit. I felt the job would be energizing if not invigorating. What I have learned is that the human psyche and spirit only has a certain amount of positive energy to give and so much negative energy it can absorb. The end result can sometimes be a daily mental and physical exhaustion. It is a job in which one is obligated to give 100% of their spirit and psychological energy in treating their fellow human beings. The real joy comes from the fact that we have a gift in the responsibility to give and to care for our fellow human being. This joy touches not just psychiatry but all physicians. Despite the pragmatic realities of health care and our technological fast-paced world, and the continued reduction of human connectedness in society, the ancient archetype of healer will remain as long as human beings remain.

I know of nothing else that I could do now. It is in my blood and in my soul. Perhaps the joy also comes from the exhaustion of giving ones positive goodness and energy in the name of healing on a constant basis in the physician’s daily professional life. Anything short of that and we should not call ourselves a physician. Perhaps the joy of giving is actually invigorating. Perhaps that gray-bearded man in the tweed suit with the pocket watch felt that exhaustion or maybe that joy."

Pending Book Tour and other Musings

2010-06-09T22:10:00.000-07:00

Book tour in Florida next week. I will be doing a reading and signing and talking about the book and all about AD next week. It's weird but I was trying to figure out which sample pages of the book I would read for the book signing. I read a part about some mean laughing on-lookers at my mother's inappropriate social behavior, when I took her to a restaurant when I was seventeen, that one seemed okay. I guess it covers some of those universal concepts of Alzheimer's family members, the ignorance of the fellow human being manifesting as mean-spiritedness-

but then I read one about a patient I had, whose wife had AD. It was quite a few years ago, I actually got choked up reading it. I have had thousands of scenarios like that. You don't get to get choked up as a doctor-ever, no matter how much it goes against your human nature. This is especially true in psychiatry. I guess that is one of the reasons so many people hate psychiatrists- shrinks. I spose oncologists get to cry with their cancer patients and that is cool, but psychiatrist don't get to.

I know crappy therapists get to cry with and hug their patients, but it does not work in the end, It is boundary less. It looks coll on TV and for Hollywood. But it is not the right thing to do. You get to convey compassion and empathy without crying with your patient, most psychs don't get good at that, easy to throw meds at people. Part of the reason psychiatrists are seen as such heartless bastards.

So why don't you get to be emotional? Well it may seem kind and sensitive, but in the end, the patient is not going to know where they and you start and stop, it conveys a pseudo-trust, but ultimately the patient can't trust you, I mean your affect (emotions) will be as sad and anxious and uncertain as theirs. Unconsciously the patient thinks they have to take care of the therapist or doctor. The patient does not feel safe, it feels out of control, for them. They don't teach boundaries so well anymore, in fact you have to work at it to find good psychotherapy training in this day and age. Oh and shared experience is not the same as empathy. That is a toughy for most people to get. The ultimate sign of a good doctor, conveying empathy and positive regard to your patient without loosing your emotions and boundaries.

Yep I hear 200 tragic, painful, anger-provoking, tear-jerking stories a month. you get to be sort of an emotional factory worker, an empathy machine, cause it is the right thing to do. You owe 1,000%, you took an oath, and people depend on you with their lives.

Anyway I am amazed as I read parts of this book I wrote, some of it years before and can still become choked up.

The Helplessness of Alzheimer's

2010-06-06T14:17:00.000-07:00

The process of living through Alzheimer's disease in a loved one is essentially an emotional prison. You are stuck behind the walls of helplessness. You can't stop the disease from progressing, you can't reverse it, you can't cure it. you have no control of the situation. You are involved very passively and helplessly in a process. Sort of like being caught in a tornado, and waiting for the storm to end, wondering how much destruction will be there, and if you will even make it, and of course in the middle of the storm you are not sure it will ever end.

Prison, you freedom, your control is taken away. It leads to anger and frustration, we often end up lashing out at those whom are closest to us, the guilt leads to more anger.

You remember the loved one in better times and you want those times back, but you can't have them. People that have not experienced it feel bad or sorry, they think it is terrible, but you feel a wall between you and them. That is what the disease does.

It is diabolical, one of the worst things to experience, in our modern society, the disease is a machine that is non-stoppable, it isolates a person, physically and emotionally, it alienates siblings and family members, it should bring families closer, but it usually does not do that, it seems to conquer and divide. Every family member goes through the living grief in their own unique way.

That is all part of the Alzheimer's process. We hang on every hope, the media exploits, just it doing their job, with reports of breakthroughs, but the fact of the matter is the efforts to work together and conquer the disease are quite fragmented. The disease conquers and divides. It is isolating.

The great non-profits of the world, do their best: missions, always missions, conquer, cure, stamp out, stop the diabolical killer. Walks, fundraisers, see and be seen. Stop the disease. Remember all the tax status, non-profits have to balance budgets, survive, pay salaries, send press releases, go on with the mission. sometimes the mission of the non-profit is unofficially to survive, legitimized behind the official altruistic well meaning MISSION.

We must be doing something wrong, or it just not that important, how is it that all these public sector and private non-profits, researchers, doctors, clinicians, everyone, can not simply come together and get it done? Lots of little worlds, fragmentation's, fighting for grant money and publication, notoriety etc etc, can't come together? Fragmentation. The disease conquers and divides. The helplessness of Alzheimer's.

Does anyone who has not lived through it, really understand that forbidden feeling we all have? Hating the victim, and constantly having to remind ourselves we hate the disease and not the victim?

Worse yet, wanting it to be over, wishing, wanting, hoping the person will die, since it is so awful they are suffering, we want it over. Then we remember our loved on and who they were before the disease, and we are overwhelmed with guilt,-the living grief.. My God no wonder there are so many health problems, and depression in caregivers and family members. What can that kind of stress do to the immune system, the bodies resilience?

Sadly with what has happened to our health care, and honest to God where it is headed, I am so worried about the lack of honor and dignity placed on our aging population. Euthanasia may take center stage, and the media and politics continue to color our collective thinking. Well since we can't beat the killer lets join it.- Wrong direction to go in, I know it, I promise.

How did we essentially conquer AIDS in 25 years? Were we just lucky? Better money, Better resources? More important people had it? What is AD trying to tell us about ourselves as a society?

Is there a way to truly work together, to come together, to conquer this killer? Right now there is something wrong with the paradigm. So many self interests hiding behind the mission. Why is it so fragmented? It does not help any that we are more narcissistic and youth-worshiping as a society than ever, with absolutely no attention span and completely aggrandizing and novelty seeking. Are we redefining Altruism? At this point it seems you can't officially be altruistic if you don't have the correct tax-status. fight each other and cut the throat of others for the money, for the grant. for the publication. For the recognition. It seems we are pretty screwed up in our priorities and how we are going about this. Perhaps it should be a law that every American has to adopt a AD victim or an AD family, for even a day, an hour.

Maybe all the Alzheimer's efforts should be mandated to poll their resources. no fragmentation. Except we all know where that would go, more bureaucracy, and power struggles for control, and in the end somebody a few making money.

Well Doc Here I am again.

2010-06-01T12:18:00.000-07:00

You have nagged me to post again. So I decided to post a post that my wife posted on my blog. Is that toooo many posts. She is my main caregiver and since your blog is more to that arena, I thought it would be ok. But notice her post is not 42 paragraphs like some people we know. Love You Man.

Joe posted a few weeks ago about the fact that we have had some difficulity. He has had some issues and yes I was hurt by them. But in all fairness I guess I am to blame too. As you know he can still find his way around the computer and sometimes it gets him and others into trouble. So as a caregiver and as a spouse I am going to say that we need to ask questions when our other half is doing something that we are not sure of. We need to check the bank statements and credit card statements just to make sure there are no charges there that we do not know about. $10 here and there really add up. Also just like we do with our children we need to know who they are talking to. Whether on the phone or on the computer. So I am sure that we will have a few more arguments about how we nag and are trying to control things but, if we don't damage can be done that can not be forgiven or forgotten. Fortunately we are working on our end. So do not be surprised when he writes that I am being a nag and not liking me or others very much. We do it out of love.

Pay Attention to what is going on around the person you care for.

Lynn

The Course of Alzheimer's

2010-05-25T20:00:00.000-07:00

Good to see Joe and Karen and the resurfacing of Lisa-so glad you are back blogging again. Very dear, Loyal and good people, I can't say enough about them. We are all universally connected by this AD machine.

One of the things I have been thinking about lately is the course of this disease. The seven stages are quite well known and popular over the last 15 years. It does not matter how you break down the timeline of the disease, on a long term basis it is always predictable. One of the confusing things is that it gets diagnosed at all different times on the continuum of the illness. So it may seem to last anywhere from five years upwards to twenty years. Someone may be several years into the process when they are actually diagnosed, or very early on in the process, depending on the family, the doctor, even ones willingness to make the diagnosis, including the doctor, the family the victim.

In the early days and years the disease is quite a bit of a roller coaster ride, peaks and troughs, good days and bad days. They often happen for no apparent reason, the phase of the moon, the alignment of the planets, you never know when a good day or bad day will come, in the earlier stages. So the day to day course can be quite variable in that way. It is enough to drive anyone bonkers.

Here's why:

One a good day things seem clear, oriented, lucid, the family, the caregiver, gets this sense that maybe everything will be okay, maybe the AD stopped. Maybe it is a miracle, maybe I am waking up from this terrible nightmare. Yes we know logically it is not true, but we are all human, and it takes us for an emotional ride. we get a strange little candle flame of hope. But the next day for no reason is a bad day, disoriented, a bad scene, getting lost if driving still, leaving the stove on, getting dressed inappropriately, forgetful, confused a bad day after a good day, anger, despair, grief, a feeling of being betrayed by God or whoever you look to- a terrible emotional roller coaster.
Sadly as time goes on these are less good days and over time a lot more bad days, when you are close to it, it is tough to look at the big picture and you live day to day and loose perspective, you want to get off that ride, but you can't and you won't.
You start to hope for good days, less and less over time, you try to laugh, but it gets harder to laugh.

Yes in the big picture the course is always predictable, the various ways of breaking it down the early intermediate or late stages, it is universal and correct. But early on these is not enough credence that can be given to that roller coaster ride.
Even if we understand the stages in the big picture, it give us a nice sense of false control over an out of control situation, but it does not help to much in that day to day ride when you are so close to it, just trying to survive another day.

When Can I Go Home?

2010-05-22T08:41:00.000-07:00

When Can I Go Home? is now Available. Well after 21 years of work the book about my mother's Alzheimer's Journey is now available. I can now talk about it more freely, since it is way too late to turn back now. It is available for purchase from the publisher Niagara Press website. I started this book about 21 years ago, a few months before I graduated from medical school, about a year after my mother died, after struggling with Alzheimer's disease for about 9 years. The book talks about so many things, related to this struggle. It was all fresh in my mind back then, years of the journey. Most all of the universal moments are discussed. The behavior changes, the forgetfulness, the slipping of mental faculties. The denial-(my father died a year before my mother was diagnosed), the diagnosis, non one heard of AD in 1979, remember we use to call it "senile" or "hardening of the arteries to the brain" back in the 70's. giving my mother meds in the 1979's that really would not stop or for that matter do much of anything for the disease. Bizarre behavior, that far away look in my mother's eyes, nursing homes, a slow death every day. The roller coaster ride, windows, (some days good, some days terrible,), nursing home, losing ones home, (my mother and I lost our home at the same time) losing ones ability to drive. Its all there, all those universal moments, that only a family member of a victim of Alzheimer's can experience. its easy to identify with that part, if you have gone through it.

So I wrote voraciously for a few months, I had such a overwhelming urge to write this, to tell the world, to shout out about this diabolical process. That need came from the profound isolation the disease causes on the victim and the family. thirty years later it still does that. Yes it is a household word now, and the Alzheimer's Association is huge, and we have some FDA approved meds to slow it, and more people than ever are getting it, but in the big picture not much has changed, sadly enough. We still diagnose the same way definitively with brain tissue under a microscope just like Alois Alzheimer back in 1908.

Even though a part of me died with my mother;s disease and ultimate death from Alzheimer's I still had to go on. She gave me something, a part of her, to carry on.
I mean there was really no option but to go on.

The thing about Alzheimer's disease is that if you loose someone close to you to the disease, remember it is always fatal, for those left behind on earth, the story never ends. It still goes on, you are never the same. If you had a mother or father die from the disease, you know a part of you is broken hearted forever, thats what the disease does. but you carry on, you carry on their spirit.

You lived through the process, you want it to be over, you want you loved one to be better, but now they died, that part is over, ...now what?

Yes maybe there is a strange sense of relief, when that part is over, your loved one is not suffering anymore, but now what do you do? You go on. I went on.

The manuscript never went away, I just didn't get a chance to work on it again for about another 17 years. Its funny because thats about how long it was till I got back to the book. That's also how old I was when my mother was diagnosed. I went back to it, when I was about 44 years old, thats how old my mother was when I was born.

The problem was there is no ending to the process. and there was no ending to the book. Remember you can't write an Alzheimer's book unless it is uplifting, lots of self help, practical, etc. I was not sure the book was inspiring enough, not sugar- coated enough, with lots of hysteria on fish-oil and vitamins and cures. Yes those books sure sell, but this book may be a lot of different things, but the one thing it is is HONEST.

So how could I be a physician and not write a self-help book? Seems almost like a crime. Well I figured there are enough of those out there.

So then it is a basic blood and guts Alzheimer's memoir. All those horrific universal moments. Except I now had 17 years of experience treating traumatized, wounded, angry, lost, sad, suicidal, or homicidal, human beings, actually about 30,000 of them over the years. Yes I have done the math. It sort of colors your world. It was hard not to put those aspects into the context of the book.

So I knew I could not eliminate my world as a doctor, there are lots of nice clinical things about Alzheimer's that are explained in this narrative memoir.

The book is really about three things, my mother who and what she was before and after Alzheimer's and the horrible passive helpless struggle (the memoir), and the second part is the struggle the active laborious thankless struggle to become a doctor, the active and the passive process (simultaneous) that just how it happened, (the secondary memoir) and finally sort of a long running comment on all of this from a perspective of a boy of 17, a man and a physician, years later, commenting on all of this. Truth, honesty, and opinion, but honest. That is the part about psychiatry, mental health, medicine, doctors, Alzheimer's disease, aging, how we treat our elderly, our societal values, etc etc. That is the part I think that evokes a lot of unexpected emotions in some, tension, anger, suspiciousness, surprise, validation, redemption, at best it make some feel very uncomfortable I guess. Maybe thats good and maybe not. I mean a lot of it is the stuff we know, but like to pretend we don't. ...or don't want to.
Several things came together to help me close the book. for those who have the will-power, or like to see beyond pretense and fallacy, that is those who appreciate honesty, it will be pretty easy to see the uplifting and even self-help aspects. Some things dawned on me late in the book in regard to Alzheimer's disease. In something that never ends, it was possible to end this narrative.

Letting Go- Author Unknown

2010-05-13T20:13:00.000-07:00

Nice Poem, Do With it What you will.

Letting Go

Author Unknown

To let go doesn't mean to stop caring;

it means I can't do it for someone else.

To let go is not to cut myself off...

it's the realization that I can't control another...

To let go is not to enable,

but to allow learning from natural consequences.

To let go is to admit powerlessness,

which means the outcome is not in my hands.

To let go is not to try and change or blame another,

I can only change myself.

To let go is not to care for, but to care about.

To let go is not to fix, but be supportive.

To let go is not to judge,

but to allow another to be a human being.

To let go is not to be in the middle arranging all the outcomes,

but to allow others to affect their own outcomes,

but to allow others to affect their own outcomes.

To let go is not to be protective,

it is to permit another to face reality.

To let go is not to deny, but to accept.

To let go is not to nag, scold or argue,

but to search out my own shortcomings and correct them.

To let go is not to adjust everything to my desires,

but to take each day as it comes and cherish the moment.

To let go is not to criticize and regulate anyone,

but to try to become what I dream I can be.

To let go is not to regret the past,

but to grow and live for the future.

To let go is to fear less and love more

Blogging about Alzheimer's and Social Responsibility?

2010-05-12T19:35:00.000-07:00

   After Joe P's last post a couple of weeks ago, I started thinking about the purpose of this blog. Joe says people with AD read the blog (I am not sure who besides Joe) but then again it is a blog. Joe's posts have been fantastic and articulate, I know he works hard on them and for someone with AD, he challenges all of our stereotypes of an Alzheimer's victim.
   I wish there was a way I could get rid of Joe's disease to make him well again, for every victim and every family I wish I could do that. If someone waved a magic wand and said change your blog or stop blogging or jump this high and you will cure Alzheimer's- wouldn't that be fantastic? Joe talks of the frustration in reading this blog, not always understanding what I am posting. This shows the same frustration and the helplessness and out of control feeling I felt with my mother many years ago, as she succumbed to the disease. I still feel it for Joe and the five million other people suffering with the disease and the 40-50 million loved ones affected. All those feelings.
   I know if I tried to change the blog it would not stop the out of control disease. I wish I could.
   The posts are getting a little hard for him to read and of course being a person who happens to be a doctor and a physician and basically spending all day, every day trying to help people giving all of one's inner strength to others to help and heal them (because that is what being a real doctor actually does, ( contrary to our societal prejudice and stereotyping of physicians and psychiatrists.), I started thinking are my sometimes angry, even sardonic, sarcastic yet honest posts not nice? not helpful? not therapeutic?
   Do we blog for ourselves or do we blog for everyone else?
   I am not interested in making anyone feel bad or confusing them-with hard to read posts or in any other way, so honest to God, if you read this blog and you are a caregiver or a victim in early Alzheimer's stages and you read this and it makes you upset in any way, DO NOT READ IT. That is not the intent.
   I promise that there are thousands of blogs out there written in so many different ways, some offensive or hard to understand and some much more self-help and user friendly than this one, and everything in between.
   I hope it helps some people by providing info, knowledge or wisdom or experience, but that was never really the primary goal. In fact the primary reason for blogging was to just write, to blog. I know sometimes the posts are helpful, filled with info that might not appear on other blogs. Sometimes it is just writing and publishing, and it is about the reader, like a book, a connection for better or worse, between a writer and a reader.
   Other people get to blog freely, so why can't I, freely and honestly? Pressure and a conflict in myself. If I blog as a person who happens to be a physician, do I have an ethical obligation (that others don't) to always try to make my blog helpful to people? Thereby compromising my integrity, freedom and honesty? People complain so much that physicians are not human and disconnected, so if you are human like in this blog: I have learned that people are not always happy with that either. People are not really comfortable letting go of their stereotypes of docs.
As much as people have their terrible misguided animosity towards physicians or psychiatrists, based on their own terrible experience that they expected or they heard about from someone else, would it be better to start over and lie (like some many blogs out there and pretend I was something other than what I am?) I guess I just can't do it.
   I promise not all psychiatrists are low life weasels, but so many people need to hold onto that, serves some purpose. Frankly it gets a little old. Truly it upsets some people if you even try to defend your profession, you just can't win.
   My book like the blog, sort of lets people in on quite a few things, that are totally upsetting to read about and certainly not something the medical world openly discusses. People don't like that part, it makes some mad, I get so tired of pretense and lack of honesty, so someone needs to talk about things.
   This blog is not really clinical, it is just my thoughts and feelings, not meant to be above or below any one's intellect. Its just how I think as a human being, we all get some slack don't we? I mean sometimes it is clinical but sometimes it is just thoughts, that's the beauty of blogging isn't it?
   When I went into psychiatry, 20 years ago, I really thought it was the most humane of medical specialties in so many ways. It took many years to figure out what a scapegoat the entire profession is. Think about it, people bring their terrible upbringings to you- pain, trauma, abuse, in-humanness, terrible experiences, with an expectation that another person will fix it all. Do you think a little of the pain, rage and anger, if not like all, gets displaced onto that "SHRINK" especially when they can't fix it all. Throw in the wonderful world of psychopharmacology and there you have it.
   Perhaps the toughest part of the work, the most emotionally grueling aspect, is that as a doctor you basically give up most of your life in an effort to help others, you must treat everyone with the same empathy and compassion and positive regard, no matter how much your moral compass disagrees or disagrees with the actions of that person you have taken an oath to care for, you still care.
   In other words think about it, you get to (you must) treat a child molesting, murdering, rapist, in the same nonjudgmental compassionate way as you would that sad depressed old lady who is now widowed and whom basically gave up her whole life serving others and is now suffering with Alzheimer's disease- and do all that in the span of a half hour.

   Remember we are all connected by this disease, 5 million people have Alzheimer's. I hope this blogs helps somebody, if only by enlightenment, validation or simply, entertainment. I have considered the original intent of the blog, and always struggled with the moral or social responsibility or obligation I might have in blogging, I mean I'm not practicing medicine, I'm just blogging. Somehow by speaking the truth, my Truth, am I violating that social responsibility, probably not, I am just letting some people down maybe, by challenging some of their pretenses. If as a blogger I do have some higher ethical obligation to do whatever I can as a blogger (who happens to be a person and a doctor) wouldn't everyone who blogs, every human being have that social responsibility and ethical obligation as a human being to help others in some way? Yes? or No?

The House That Built Me

2010-05-07T17:47:00.000-07:00

One of the bittersweet things I have to deal with is visiting my folks house without them in it. It was tough in the beginning but it is getting easier. Their home is beautiful. Built in 1972, it is the only home I ever knew, as I was born in 1973. It is a large home, brick finish, roughly 4500 sf and sits on 25 acres in Northern Georgia. Pines, tulip populars, cherry trees, azaleas, countless bulbs, tulips, lily's, mom and dad have gradually landscaped it over all of these years. It hurts me that they can't be there. It also haunts me, in a good way, with a lifetime of memories.

I, of course, still deal with daily grief, I actually call it "survivors guilt" related to my parents as well as the day-to-day stuff related to managing both their estate and their health. Recently I heard a song by Miranda Lambert called "The House That Built Me" Listening to that song literally heals my soul. It entirely describes how I feel when I visit their house and my late grandmother's house which is right next door. I am including a link to a youtube video of Miranda Lambert performing the song and talking about the beauty of the songs lyrics. I hope you enjoy it as much as I do!

Miranda Lambert - The House That Built Me

Living with Alzhiemers'

2010-05-01T09:01:00.000-07:00

Library Thing and Good Reads Reviews

2010-04-28T20:53:00.001-07:00

This is what I was talking about in comments to Edna in previous post.

http://www.librarything.com/work/9530764

http://www.goodreads.com/book/show/7632743

To Dr. Joe

2010-04-25T12:27:00.000-07:00

Doc,
I am having some problems with your posts. For me they are not simple enough. We with this disease really have problems with professional type language. This is not a complaint, just telling you my side when I read your posts. I know your site is for caregivers and to help them. But I know a few of us with AD that read your blog, they may also have this problem. I still consider you a friend, even is you are a shrink. That does not make you bad. My day today is, I sucked up my blog, brain is shrinking and so is my understanding of what I read or attempt to.

God Bless You My Friend,
Joe
http://living-with-alzhiemers.blogspot.com/

Driving with Alzheimer's Disease

2010-04-25T10:57:00.000-07:00

There are a some pivotal moments in the Alzheimer's journey. Moments that are never forgotten by family and caregivers. They often have to do with loss of autonomy. They are symbolic and somewhat embedded as trail markers in the long journey. Kind of like climbing a mountain, when you get to the end of the tree line, or the first glacier, or the bivouac. The Alzheimer's journey is an uphill climb, except at the end of the climb you are not necessarily rewarded with the beautiful view at the summit. Oh well enough metaphor.
One embedded moment is the diagnosis, another is the loss of one's home, entering an assisted living, or nursing home. Another is driving or the loss of the ability to drive. It is a profoundly emotional moment.
One of the most poignant things about it, is that the disease robs the person of the ability to drive, but being the ugly little entity the disease is, an actual person, has to take it away from the victim. The doctor, or a family member, or some state employee, or worse yet contracted county employee working for the state at the department of motor vehicles. We all know how empathic our civil servant public employees can or can not be.
As a family member I have personally lived through the driving issues. As a physician I have lived through it many times more with patients and families.
It is never pleasant from any end. I talk about it a lot in the memoir. In my own personal situation, my mother was loosing her ability to operate a car. A big part of the problem for her and for most, was not the actual operation of the vehicle, but actually finding one's way, around in familiar, places. Next was the depth perception and visual-spatial issues.

Ironically, my mother was still a licensed driver, but loosing her capacity to drive. I was just seventeen, and had gotten my learner's permit. I had more capacity to operate a motor vehicle than she did, but I could not drive the car without a licensed driver in the front seat, which was my mother. I hastily moved towards getting my regular driver's license as soon as the laws permitted.

With the loss of autonomy for the driver, comes more responsibility an sometimes burden for someone else. That is a tough thing. We don't ever like to use the term burden. For some it is not, other's deny and still others thrive on taking over the transportation responsibilities. (Not to many really, but we don't admit it because then we struggle with the concept of selfishness)

Without a doubt since the end of the industrial revolution, and going back to the days of Calvin Coolidge, the writing of Sinclair Lewis operating a motor vehicle is the ultimate symbol of autonomy and power. We even make cars to be a status symbol and a signature of who we are. Remember when you were a teenager and got your license? Did your life change?

So what happens? Often the victim has a sense that they are not a good at driving and what it entails. They may be anxious or not want to drive in unfamiliar places, but they can't quite articulate it, so it is up to others to figure this out. That leads to one of the most common phenomenons I see as a doctor. Driving the familiar routes. Only to the store, the gas station, the beauty parlor, to church. Just a few blocks or miles, sometimes a route driven for forty or fifty years. The route may not have changed but the disease changed the person.
So I commonly have gotten over the years this: "Mom or Dad, only drives to the store, or to church. There is no one to take them to the store or to church. They are comfortable with that. That's OK right doctor?"
Well sadly it seems okay, but the honest to God truth is, it is probably not okay. Remember Alzheimer's is a variable disease, on a day to day basis, with a downward decline over months and years. There are GOOD days and BAD days. Some days the driving will be spot on, and others maybe not so much. You never know.
The doctor once again gets to be the non-caring and non-understanding bad guy. The bearer of bad news. The messenger gets shot. The doctor does not get it. They only drive to church and the store. The doctor is a jerk, Let's go to somebody else that says its okay to drive.
The truth of the matter is, you can find another doctor who may look the other way, these may also be the docs that are rather apathetic in trying to treat the disease. -since there is nothing you can do about it ultimately- bad attitude.
Remember most accidents happen within a mile or two of home. a motor vehicle is a potential deadly weapon, sorry it just is.
Notwithstanding the fact that there are a lot of really crappy drivers on the road. Driving is w weird thing, most people believe themselves to be an above average driver. Not to mention the fact that you have little rude hormone boys under thirty thriving on the pseudo power of the vehicle, and with each generation, now angry little rude girls also driving with that false sense of power. No respect for others or the deadly weapon they are operating. Not to mention the fact of all the 45 year old victimized by life adolescents, who are operating the weapon under the influence of mi sued alcohol or whatever illicit drug, they use to make there life seem better, Then we have the popular misuse of benzo's and the ever popular ambien, and opiates. Of course we can blame the doctor there. Prescription drugs are a problem, and society continues to minimize how we throw these around, so when the doctor takes it more serious than society, people don't like it, so they go to another doctor.
So throw in the Alzheimer's victim, it robs your judgement and reaction time, throw in everybody else on the road, and it is a bad set-up. The poor AD victim may not be able to react to all the carelessness on the road by others, let alone themselves. And Yes there are bad drivers within a mile of your home.
As a Doctor it is less tense when the AD has stopped driving on their own, or at a family member's urging. That is not often the case, so the doc has to start the process. This is not to mention the fact that the doc is also responsible for whatever happens on the road. Hence lots of lawyers. So it is a legal thing and an ethical thing and always painful for everyone taking away the privilege to drive.
So the doc sends a letter to the DMV, depending on what state you live in.
Here is the best part, the public employee at the DMV can sort of do whatever they want, not so much accountability for behavior day to day, as you may or may not know in the public sector, The DMV employee may be nice or mean. It is about them and if they have a bad day or family life or whatever. Hence they may give the AD victim one or a few chance to pass the test. They may start over. Yes it is all computerized, but believe me there is leeway depending on where you live. In addition if you live in a small town your loved one may even know the employees at the DMV. What do you think will happen- there is some variability depending on how the employee feels about your loved one over the years. Throw in the factor that your loved one may be having a good or bad day, when they visit the DMV. You have a total crap shoot. They may or may not pass. If they don't pass, the chips fall and lots of consequences, and change. If they do pass, everyone sort of denies the illness a little bit and life goes on, and God forbid nothing happens on the road.
This is why nobody knows what to do in the end about the driving issue. The neurologists tried to develop some guidelines recently but i9t is still a major quandary. In the end family members are still in limbo and filled with anguish over this. Doctors get to be once more vilified over it. It is heart-breaking and scary. It is a sad moment and part of the ugly process of the disease stealing from the person and their dignity. It can be pure anguish for the family. It is a universal moment filled with a myriad of emotions. You are not alone.

Effexor Wishes and Seroquel Dreams: My Place for Peace and Serenity

2010-04-22T09:26:00.000-07:00

Effexor Wishes and Seroquel Dreams: My Place for Peace and Serenity

Why is bipolar a stigma but not depression?

2010-04-20T23:14:00.000-07:00

What is amazing is how far we have come in eliminating the stigma of depression. It is now more okay than ever to speak of depression, to know what it is and even admit you might have it. But God forbid if you have something else. Take bipolar disorder for example, poorly misunderstood, feared, hated, stigmatized and generally a black mark to have, by our unforgiving society. Probably over-diagnosed in some venues, and yet missed in many others. The depressed part of bipolar, looks just like major depression, indistinguishable in that phase, from unipolar depression, that is why it generally takes on average of about 11 years for someone with bipolar to actually get the correct diagnosis, and therefore treatment. Plus it feels pretty good to be manic, till it gets to be a bit much. Sometimes the only subjectively bad part of mania is overwhelming anxiety. Objectivity can be lost by the sufferer.
Here is the actual problem that nobody seems to get, even lots of doctors/
Most people with a mood disorder do not fit into a perfect box or pigeon hole. There is a whole area or bipolar spectrum disorders that don't fit the classic DSM-IV definition. The so-called "soft bipolar' disorders. The truth of the matter is, it is on a continuum Hence for these individuals lots more antidepressants prescribed, remember it is easy to diagnose the depressed part. And whats great is that most of the antidepressants are approved by the government for treatment of anxiety. Except there is probably more anxiety associated with the bipolar spectrum problems than major depression. Antidepressants generally will stop working at some point for people with bipolar, or even make things worse. That is why correct diagnosis leads to correct treatment.
If you mention bipolar, the gloves come off. If you simply discuss "mood cycling", kind of like a roller coaster, except cycling enough to cause problems, then everything is okay. It is a safer way to say things. It gets away from labels, and the vicious cycle of stigma. It is more acceptable. Then you can get down to actually discussing treatments for the mood cycles. You don't have to argue about the diagnosis anymore, when you just treat the person, and their symptoms- One needs to get away from labels
Maybe the problem with Alzheimer's is similar, the same with dementia. Let's face it, there is still a big stigma, if there was not, we would be a lot closer to a cure. Perhaps if we called it something like "cognition slip" instead of Alzheimer's, people would stop reacting to it as if it is the plague or some black mark on one's spirit.

They Say Phsyc's Know What They Are Doing!

2010-04-15T19:54:00.000-07:00

Hello,

My name is Joseph Potocny, you see Dr. Joe and I have known each other for sometime now. But let us question his sanity, he is a MD I am an AD (Alhziemers person) and have FTD as well. Now who knows more him on the far left or me on the gentle right.

I thank Doc for asking me to blog here, I guess he is ready to be punished for the well shall we say less than upstanding life he has led. Not true, he is a good guy.

I have had the disease for over 3 yrs confirmed, by the time you know whose professsion would listen to me. So today like many days has been filled with times of where the hell am i and what am i doing. I was going to do this as a video, but he told me creatures were not allowed to appear in person. I read docs' blog daily as he makes posts, some I just do not understand, that is the way it is. Others he is right on. See he was a victim of this disease on the other side and could not understand why his mom was leaving him. I live on the other side of the tracks and do not understand why people are leaving my brain and world. By the way Doc and I are getting married next week last I knew.

I hope to be back latter, but with a more direct post that I do as normal. Just to prepare you visitors and friends of Dr. Joe, I am very blunt and not always choosey about my words. Nor do I use spell check. Read his book, I think you will find solace and vindication in it ( wow big words ) must be getting late. I needed help from my wife with my thought processs on trying to understand it. But I need help in finding the bathroom.

God Bless & Keep You & This Country of Ours!

Joe

http://living-with-alzhiemers.blogspot.com/

Health Care Reform

2010-04-09T09:24:00.000-07:00

As a doc, I often get asked the question, what do you think of the new health care reform? I can give the usual answers, "Well we needed to do something." "I am cautiously optimistic." These are true statements. The plight of the physician in 21st century America seems at best to be uncertain. That is what it is: a plight. It is hard for me, just like everyone else to predict exactly what is going to happen. It is so convoluted and complex, thousands of pages and issues. So many gradients and steps. I do know as a society we are more in the "here and now" and all about immediate gratification, more than ever. That is no different in the personalities of politicians and lawmakers, than it is in anyone else. We are all about image and appearance in the here and now.

Being in the here and now is fine for meditation, but I am not so sure it is fine for making laws and planning for future society.

So the facts I can speak of are true and relative to my plight. I know right now I would be deathly afraid, like so many Americans, not to have health insurance. Life is unpredictable, and you can't live your life and plan for castatrophe but on the other hand, things do happen. Anyone reading this knows that. Hence things like AD in a family member etc. Hence many of us know this and maintain health insurance as best we can. My family is in pretty good health and for an average policy we have to pay nearly a thousand dollars a month. I am quite certain that those premiums will go up considerably with health care reform. Once again trying to do the right thing and take care of your family, often seems to go with punitive consequences.

That issue of the insured premiums having to go up in cost to cover those without insurance is an absolute farce. I know that many people only access care in the ER and don't pay a bill; those debts go somewhere right? It would be most interesting to truly trace a dollar in cost for health care. If the insured covering the uninsured and thus paying higher premiums was actually true and not a "catch-all" chant, the insurance industry would be more like: breaking even. That is actually not the case, is it?

From the perspective of a physician practicing on his own in Northern Minnesota in 2010, here's what else I can tell you as fact.

Right now it is almost impossible to treat a patient with a prescribed therapy and medication without fighting with an insurance payer to get that prescribed therapy covered. Every single day I fill out forms, requests, appeals, protests, to try to get a patient their appropriate medication. You don't get to be a doctor anymore, because that struggle takes lots of time, so it takes you away from trying to take care of patients.

You struggle with people that are sitting on the phone in some cubicle, who don't really know anything about patient care and most importantly the name and the face and the life of that patient or any patient of a doctor to whom they are denying care.

They are working right; trying to make a living just like everyone else. Public sector and private sector employees. They are basically taught, in so many words that the physician is the "bad guy". It is ingrained and instilled in them, at their little week-long training seminars at some Radisson or Holiday Inn (lunch included), that the physician is somewhat of an advesary; trying to prescribe expensive and unneccesary treatments. Now they might not fundamentally have that "chip-on-the-shoulder" prevasive American attitude about doctors, yet it is pretty easy to tap into. It get's you kind of fired up and believing. Plus you get to make a living. It is almost justice, yet no name or face to the patient, the person needing the treatment. It's not new and it will get worse, I can see it everyday in my practice.

One of the saddest parts of the plight is that the patient holds the doctor accountable. It is just human nature. So you have the insurance company demanading that you prescribe what they want, You know as the doctor, it is not the optimal therapy. You advocate and fight for your patient. We used to win those battles but over the last year, we are consistently starting to losse those battles. no matter how hard we fight. In the end it is still about the doctor-patient relationship and that human connection, not the insurance company. In the end, The doctor has let the patient down, not the insurance company, More devisive, more advesarial, than ever. I promise you: that will only get worse. And the distribution and justice and equity and fairness, just does not loom on the horizon with health care reform.

I think it was absolutely pathetic when President Obama had all those people, (physicians) standing around in their white labcoats, for photo ops. How stupid do we really think the American people are? How demeaning to physicians. Sort of like a beauty pageant or a dog show. I mean more importantly those people in white lab coats standing around for the photo ops, (physicians right?)- who exactly was taking care of their patients that day? Maybe their partners, right?

Heres another fact, in Minnesota I still get to keep paying an extra 2% income tax called the provider tax, a tax to cover the uninsured. If you take care of patients and make a livng at it and don't work for some large corporation or institution, where it is all rolled in and you simply get a W-2 at the end of the year, well then it is not an income tax right? For me it is an income tax, since I derive my living directly from caring for patients. No filters, no employer. I promise you it would feel so much better if we actually covered everyone in Minnesota, but there are still thousands without insurance. So where does my extra income tax, (2% back to the state for taking care of patients) go? God only knows. If only we could get rid of the small or private practitioner everything would be better right? A dying breed. A thing of the past. Sort of like the airlines or banks. We only need a couple of health care entities, corporations, that will improve health care right? I mean look at how good the banks are doing, and the airlines.

Let's look at the VA, the largest health care entity in the USA. In my experience from patients I talk to, you either have a fantastic health care experience or an awful harrowing one. That's just what I see and am told directly by patients. Not too much equity or fairness or consistency, just sort of hit or miss. The private sector is not much different. The idea seems to be: more people managing health care, more executives, more people employed in the health care industry, trying to make a living, governing the care. (oh and going to lots of meetings, focus groups, committee assignments, clip boards, Coach briefcases, company or federal credit cards, hotel check-ins at government rates or corporate rates, for more committee regional meetings and retreats all around the country, first class or coach and basically walking around as health care executives)- somebody has got to pay for ALL that. No patient name, no face.

Eventually there will be no choice, there will only be a couple of entities, and payers, governing all of health care. Does less choice improve quality and the health care experience? Maybe, maybe not. I know as human beings, it is nice to have options, choices. Right? Sort of helps the human spirit. Less choice and more monopoly is not the same as justice or decent care, but few seem to get that.

Here's another FACT I can tell you. Remember that mantra, ever so popular, "You get to choose your own doctor". Well here is the honest to God truth in my plight. There is this entity in Minnesota called GAMC. It is an arm of Medicaid. Starting June 1st, patients with this insurance, have to go to a designated provider, a care coordinating organization, a big entity of which I am not part of-(to thy own self be true). There is a clump of money to cover all these patients given to large health care entity: no more no less. Some patients cost a lot to care for and some don't cost much, right? If you come in under cost at the end of the year you win if you spend more taking care of patients, you loose. It is called capitation. A ceiling or top. It is something I first heard of in 1990, back in New York state during my residency. It didn't work back then and it went by the wayside,- most states learned from that, but now it is back. Nice incentive right?- That good old capitation.

So the bottom line with this GAMC is that patients with this insurance, many that I have followed for years, are not allowed to come and see me anymore. They have to go somewhere else. Not a problem right; the large institutions have good doctors, no question, and also lots of other people in the doctor role, providing medical care, like nurses, and physician assistants and things. Cheaper and all, and no of course it is not watering down the care. No problem. But if you even remotely imply that maybe the physician still offers something the nurse prescriber does not, you get annihilated. That is the most politically incorrect thing of all time. The fingers point and the physician looses. Arrogant, prima-donnas that those doctors are, right? Easy to be politically correct on that one, patient does not get too much say.

So my patients with GAMC don't get to come and see me anymore, they get to change their doctor sometimes after many years. The government provided insurance says so. No one notices that good outpatient care prevents inpatient hospitalizations. Wow.

I wrote my senator, Yvonne Prettner-Solon. she wrote back and said she didn't like it; she voted against it, was on my side and that was it. She is a democrat, in Minnesota, unbeknown to most around the country the democratic, party is called the DFL. It stands for democratic farmer labor, a remnant of days gone by, but it sticks. She is a nice person and a psychologist- my state senator, but there was not much she could do for my plight, and more importantly the plight of my patients. Roll the dice, hope for the best, lets how it shakes down. PATIENTS DO NOT GET TO CHOOSE. Sorry but that is the honest to God truth: One little example in my little corner of the USA on the Western tip of Lake Superior. It is really happening, and there is a tremendous momentum of more to come.

I called my local news; it was pretty easy to get interviewed. It was actually easier to get on the news, than it was to get an appointment with a physical medicine and rehab doc at one of the large institutions for the herniated discs in my neck. No lie.

So they interviewed me. I talked for 20 minutes. I got a 10 second sound bite, that at least covered my most important point. The physician-patient relationship; the therapeutic alliance is still the most important thing in health care.

The tease for the story was "GAMC creates headaches for some private physicians in the area". Nice divisive tease right? Make it about the doctor, subtly reinforcing that adversity. They could not mention the fact that it is about the patient and what that it will all actually mean for those human beings. It is something that it is actually significant for those human beings, those names and faces, that have to, after years, disrupt their care. If we make it about the physician having a "headache", we can deny the reality of what is really happening right? Get lost in our emotions and subtle reinforcing of that physician adversary. Oh well it is only the media, but I tried. It is not like we believe everything we here on TV and read on the Internet, or is it?

Put it this way, I came from a long line of physicians, my father who died when I was sixteen was the first; he inspired a lot of others. My son is 14, I always had a vision of him maybe going into medicine. I guess he would be better off becoming an attorney, he will do what he does, but I am not steering him towards medicine. I just can't do it. I see the doctor and the healer, the ideal, simply deteriorating. Every single day, every year, every decade. That is so very sad.

2010-04-05T14:07:00.000-07:00

Hello all. Just a quick blog and an excuse to upload a picture of my dad and myself. My daughter, wife and I visited my folks at the memory care home yesterday on Easter. I go visit them every Sunday no matter what and take my daughter. It is always tough to visit but we look for the bright spots. One blessing is that my daughter still has a strong connection with my folks. She is not shy at all and will play with them non-stop. She has visited every weekend since my mom moved in with dad. She played blocks with grandma and grandpa yesterday for about 30 minutes straight. Dad seems much less agitated when he is playing with her. He lights up. My daughter and I make a day of it and usually grab daddy/daughter lunch on the way back from "grandma and grandpa's new home."

Couple of weeks ago I visited and had on my Georgia Tech pullover (I'm a GT alumni). Dad saw me walk-in with that GT shirt on and immediately went to his closet to pull out a GT hat. That was totally cool. I gave him that hat several years ago. We clicked a pic of that visit and I wanted to share. Thanks be to God.

WTCM 580 AM Traverse City, Michigan

2010-04-03T12:04:00.000-07:00

http://www.wtcmradio.com I will be back on the radio in Traverse City, Michigan on Monday April 8th at 9:08 Am on the Norm Jones Show talking about the book and AD. You can listen live on the link, or if you live in the area tune in. 580 AM Talk Radio WTCM.Happy Easter and Passover.

Joe Potocny Living With Alzheimer's Blog

2010-04-03T09:38:00.000-07:00

I would like to thank Joe Potocny for the honor of being invited to guest blog on his piece of the internet.

http://living-with-alzhiemers.blogspot.com/

Joe has Alzheimer's. Joe is a tough, smart and dignified guy. His mission is to help us to all remember. Joe lets us know that you never ever cast aside a human being who has the disease. It is as simple as that. He has a fantastic blog and you see his essence and spirit in the glowing faces of his offspring. The disease never ever takes that away. Joe read my memoir When Can I go Home? I was greatly honored to get his thoughts and his review. I mean why not just ask someone who has the disease? They are people just like everyone else. They count and they matter. Sometimes it was a little hard for him to get through the pages, he did it, he took it seriously and responsibly, because he knows it matters but most importantly: he matters.

My gratitude for him knows no bounds. go to his blog and read his thoughts, his feelings. This disease is not about what we assume it is about, it is about names and faces, people who matter, human beings who count.

Here's to you Mr. Joseph Potocny.......

SSRI's Part one- Audio podcast

2010-03-28T20:30:00.000-07:00

Link to this podcast on SSRI's http://limbicdoc.podbean.com/ (click listen now) once you are taken to the link or click on the podcast in the left hand margin to listen,

Radio Tour for book- WSVA 550AM Harrisonburg,VA and WOND AM 1400, Linwood,NJ

2010-03-16T12:48:00.000-07:00

I have a couple more radio stops for the pre-publication radio tour for book-When Can I Go Home?
Will be on Barbara Altman show on WOND 1400AM in Linwood, NJ- (Atlantic City area) on Tuesday March 23 at 11:15 am EST. http://www.wond1400am.com , I think you can listen live to that program from anywhere on the web.

Also on WSVA 550AM Harrisonburg,VA Mike Schikman show on Friday March 26 at 3:10 PM EST. http://www.wsvaonline.com/joomla, I don't know if the have live web streaming.

Wisconsin Public Radio had fantastic callers, it validates my suspicions that everyone has a special and unique Alzheimer's story and so deerly and desperately need to be heard.

Listen Live on the internet

2010-03-13T15:24:00.000-08:00

Monday 3/15/10 at 8am CST, I will be discussing Alzheimer's disease and my book When Can I Go Home? on the Wisconsin Public Radio Network. The Network has a live stream on the web. Here is the link

http://www.wpr.org/webcasting/live.cfm

Grieving the Living

2010-03-10T11:30:00.000-08:00

I would like to thank Dr. Sivak for the invitation to become a guest blogger. I dearly appreciate it! In January of 2010 we moved my father, 71, in to a memory care home. Dad has dementia, either the vascular type or the Alzheimer's type or both. About three weeks later my mother joined him in the memory care home. This was unexpected but necessary. My mother, 70, has a long history of mental illness and prescription drug addiction. Some combination of the two has led her to have memory problems herself and specifically what I would call amnesia both anterograde and retrograde. These amnesia and memory problems have been coming on very slowly over the last several months and have become a lot worse in the last few weeks. This, obviously, has eliminated my mother as an adequate caregiver for my father. Hence, the move to memory care for both of them.

One of the things that has struck me has been the fact that I am having to grieve the loss of my parents despite the fact they are still alive. This will be the focus of this blog entry. I never like to view myself as a victim but in this situation I have had a great deal to cope with emotionally and logistically. I am my parent's only living child. My sister committed suicide almost ten years ago at the age of 40. Now that they are where they are, they have ceased to be parental figures for me, rather, we have now switched roles. The way I view it, my parents have died though not physically. I am grieving this loss, everyday. And, I think it helps to view it that way. I can still connect with them both emotionally when we visit, we can still talk about shared long-term memories but the relationship I had with them in the past has ended. The impact of this loss hit me square in the face last week. I had surgery on March 5th to have my gall bladder removed. Mom and dad were of course not there and we decided to not tell them about the surgery. There was no reason to, it would just confuse them and/or bring them short-term anxiety. It was the first time in my life that I experienced something scary/difficult and my parents were not there. My faith in God really helped me however and right up until surgery and after I felt very calm and at peace about the whole thing. My two uncles (mother's brothers) both showed up at the hospital and my wife and daughter were there to greet me after surgery. God is good. Throughout this process I have leaned every resource I can find: friends, family, God, and other professionals. It is the combination of it all that has allowed me to not only survive but in some respects thrive. I choose to fight! On my last visit with my folks, on March 4th, 2010, all of the complexities of their situation were in play and my need to grieve and let things go was fully tested. My father was quite agitated and angry with me during the visit. On some level he knows that I am the one responsible for him being there. At one point he told me that he never wanted me to visit again. I am to the point where I am not taking that kind of stuff personally but I would still rather not have to hear it. By the end of my visit however, my father was hugging me and telling his nurse, "this is my baby." I have decided when at all possible, I am going to take my 3 year old daughter with me on visits, her cuteness and beauty tend to distract both my parents and deflect some of the pressure off of me! Plus, she needs to see her grandma and grandpa often anyway. During this same visit on March 4th, I was reminded again how severe my mother's amnesia has become. Eleven months ago my maternal grandmother passed away at the age of 94. We were extremely close and she lived next door to my parents. My mother was the person that called me to tell me my grandmother had died, we had a funeral, settled her estate, cleaned out her house and we all still miss her dearly. However, my mother now has no recollection of my grandmother's death (her mother). She now speaks of my grandmother in the present tense and still thinks she is alive. It is really tough for me to wrap my mind around that. The only thing we can do is play along, we tell mom that grandmother is doing fine. No need to tell her otherwise.

Both before and during this process I secured the services of a geriatric consultant. Nancy Kriseman, LCSW has been a wonderful resource to both my parents and my folks. I don't know what we would have done without her. Recently, after things had calmed down, she wrote me a note. In the note she said "remember to take care of yourself as well as you have taken care of your parents." I think about that almost everyday. In closing, another way I have dealt with my grief is through writing, the article about my father that Dr. Sivak mentioned was part of that. Writing seems to help me organize, express and process my feelings. Thanks to Dr. Sivak for giving me another opportunity to both write and heal. And thanks be to God.

John H. Pruett, Jr., MS, EdS, NCC, LPC

Founder & Owner

Georgia Professional Counseling Center, Inc.

http://www.georgiaprofessionalcounselingcenter.com/

http://www.linkedin.com/in/johnhpruettjr

http://twitter.com/CounselorGA

Guest Blogger and Radio Interview and other stuff.

2010-03-09T21:47:00.000-08:00

I seem to get a lot of queries about SSRI's so I am going to try and technologically advance and do an audio podcast on them over the next week or two. I don't know how it will go, so bear with me.

I will be on Wisconsin Public Radio this coming Monday 3/15/10 at 8am CST, talking about Alzheimer's and When can I Go Home? So if you are the neighborhood of Milwaukee, or Madison, or north of Chicago, or East of the Twin Cities, tune into your local WPR affiliate.

Now I have had this blog up for maybe 7 months. I am sure you are as tired of listening to me as I am, so it is time to move into a new realm. The realm of guest bloggers. I will have my first one coming on in a few days.

His name is John H. Pruett Jr. He is a therapist and counselor down in Georgia. His father has Alzheimer's. Not so long ago, I had the honor and pleasure to be able to read a little story/tribute he wrote about his Dad. I don't want to sound too cliche' but it was pretty moving and just a really decent, honorable little piece. The bottom line is John writes from the heart, he respects and cherishes that father-son bond, a bond that is now painted but not broken by Alzheimer's. The bond of the parent-child really resonates with me, so anyways I asked him to come on the blog. I told him he can write about whatever he wants, but it does not matter, he's a good, decent guy and a good, decent son. It should be fun.

ALZHEIMER'S IN THE NEWS

2010-03-09T16:38:00.000-08:00

Major news outlets buzzing about report released by the Alzheimer's Association today. It all comes from a press release from the Alz Assoc. It is always good and important to keep this in conscious awareness. Data comes from a Federal Survey, not sure who conducted by, but the just of it is that African-Americans are at twice the risk of whites, and Hispanics 1.5 times greater risk than whites at developing the disease. It does point out the relative under-diagnosis in these racial groups. I think the point is that part of the rise in these numbers, is that fact that it is now being diagnosed more often in these racial groups.

Alzheimer's does cut across all socio-economic groups races and religions. It will be important to see how this new report affects research funding, I certainly hope it does in a significant way.

It is still underfunded, relative to other diseases, and still profoundly ignored.

Its an awesome press release and the Association is doing their job at raising awareness. I wish it made the nightly new every night. It is impossible to over-publicize this problem and health epidemic. A sound bite from someone on the news called it the "Silver Tsunami" in terms of the continuous increasing numbers, and projections over the next 20 years.

Not a coincidence of this release today is the fact that tonight the National Alzheimer's Gala at the National Building Museum in Washington DC is tonight. Tickets are $500 a person.

press release.

http://www.alz.org/documents_custom/FINAL_F-F_2010_General_Release.pdf

Dementia-agitation, treatment

2010-03-06T08:44:00.000-08:00

Now one of the biggest stressors for family members is what do you do if your loved one with Alzheimer's is agitated and lashing out, or agitated and wandering off at night. What if they are moving about and wandering and confused? Are they more likely to fall and get hurt? Sometimes. This is typically a problem in the later stages of Alzheimer's and not all people in the later stages of Alzheimer's get agitated. Some do, they may even get violent. Remember this is the disease and not your loved one.

Yes it is true that there are people who have a history of violence and anger and agitation well before they develop Alzheimer's. Think of the violent or antisocial or sociopath. In my world as a psychiatrist those problems are all too common, but for the sake of those reading this blog, violent, dangerous people are the exception and really not that common in society. Yes violent dangerous sociopaths are people too, and I as a physician get to treat them with compassion, dignity and human respect, no matter how much I disagree with their values and the choices they have made. Another profoundly stressful thing at times which goes with being a professional and a physician. Another fact that is overlooked and very taboo and considered maybe even unprofessional to even admit, but yet very, very true. By the way as another aside, most people with mental illness are not violent or dangerous, especially schizophrenics, another fact commonly overlooked. enough digression and back to dementia.

Lets assume your loved one with AD was once a decent citizen, with no history of violence or agitation or any history of ever hurting other people. Now they are physically lashing out. Remember it is not them it is the disease, it seems to change personality, remember. Uncharacteristic behaviors emerge. Maybe your loved one is now taking their clothes of or making becoming hypersexual and inappropriate in that area. Remember it is the disease not your loved one.

Hypersexuality, wandering, violent aggression. It does not happen to everyone in the later stages of AD, but it does happen and it happens a lot. It is awful, it feels indignant and it is humiliating to live through as a loved one. It is something that many face and it probably is not addressed enough, because it is such an uncomfortable topic. Typically it is seen in the nursing home setting, when caring for the loved one at home has just gotten to be too unsafe. And yes there are people with AD living at home in the later stages who for whatever reasons, financial, guilt, emotional exhaustion, lack of resources, isolation or whatever just can't or won't place their loved one in a nursing home or assisted living. Every situation is unique and can't be judged either way. Entering a nursing home is a terribly emotional and painful situation for a family and a person with dementia. Sadly it is quite inevitable for many, if only for safety reasons, which is a big reason.

so what do you do to treat these problems of aggression or wandering or hypersexuality? Obviously you have to help the person calm down. There are basically three ways to do this. The most humane which does not always work is environment. A soothing calming relaxing environment. Soft calming music, maybe from your loved ones era. Reasonable lighting, enough light but not overpowering. Activities, attention, calmly talking to and with your loved one. Decent nutrition, some nursing home and assisted living facilities are better at this than others. Like anything else, some are great and some not, most claim to be, and if the environment, is the best thing to treat the agitating behaviors. Sadly it does not always work. Another problem often overlooked is when you take a person out of their home environment after 40 or 50 years, because it is just not safe, the new and foreign environment can sometimes lead to or make agitation worse. Why wouldn't it? Sometimes it settles down with time and sometimes not.

The second way to deal with aggression or lashing out, is physical restraint.

The posey, that thing that looks like a net that fits across the torso of a person and keeps them belted if you will in a chair. nobody wants to see this. It feels indignant and inhumane. We get angry at the doctor, the staff, and everyone else. The alternative is wandering, falling, assaulting other staff or residents. It is awful. There are various rules and laws regarding this, but when it is considered unsafe, sometimes the facility has to resort to this. some may use it more than others, that depends on the rest of the environment and your loved ones symptoms they are displaying. It is profoundly painful for loved ones to see this, it stirs up every raw ugly painful emotion associated with the diabolical disease.

The third way to treat violence and aggression or wandering is chemical sedation/restraint. Now the obvious problem usually overlooked but faced by thousands every single day, is that fact that calming your loved one down with meds can mentally slow them down more. They can become too sedated and sluggish making the Alzheimer's seem much worse. Obviously ideally a balance has to be struck. calm but not sedated is the goal. Right? This lead to the common dynamics of the meds actually becoming more of a villain. Throw in the fact that the doctor only seems to spend a couple minutes with the patient and does not see them that often and you have lots of high emotion and tension. some docs are way better than others, but I promise you no matter how much time the doctor spends with you, is kind, caring and compassionate, it can never be enough. That is the nature of the disease. remember most docs may have ten or twenty of fifty other families going through the same thing. A good doc will never ever say I have more patients to get to. In medicine, unlike anything else, patients are not customers, they are patients, and moreover they are people. That is regardless of the fact that the health care system seems to be moving in a most negligible direction, with the doctor patient relationship, continuously being placed as the lowest priority, regardless of what anyone tells you. I could digress into that issue all day, but suffice to say despite all the realities of our society and the health care debacle most docs went into medicine to help people like your loved one, some are way better than others at conveying compassion and empathy, it is a fit or a chemistry, and you know when you have a good one. Remember just about every issue in the geopolitical world, demands the doctor to be this way, and presents an environment and situation where it is becoming almost inhumanely possible to do this. The good docs don't make excuses. Back to the meds, there are many that are used to calm, sedate, and yes chemically restrain persons with AD. I have previously written about SSRI's and touched on antipsychotics. They have there own host of problems and warnings in dementia patients. It creates another quandary. What to do, no perfect med or situation, regardless of what anyone tells you, each situation is unique, sometimes the meds work wonders, not cognitively clouding the patient yet treating the aggression or wandering or hypersexuality quite effectively. sometimes not. Sometimes the meds increase the likelihood of taking a fall. Sometimes they decrease wandering and the likelihood of taking a fall.

The meds to treat AD specifically, aricept, exelon, namenda etc, sometimes help these symptoms and sometimes can make the aggression worse. There are several classes of meds used, and each person responds slightly differently. In future posts I will try to cover the salient features of the common meds and classes of meds used in people with AD.

what are Antipsychotics?

2010-03-05T14:33:00.000-08:00

Antipsychotics are a group of medications used to treat a whole host of disorders and symptomatology. Generally speaking they are terribly misunderstood, dreaded and the subject of much hatred and controversy. They stir up a lot more emotion than say an anti-hypertensive to treat high blood pressure or an oral hypoglycemic to treat type II diabetes. They are also responsible for saving many lives. They are also responsible for helping many chronically mentally ill people live and function outside of a state mental facility.

they have been around for a long time, the original developed in the early 1950's and that was Thorazine. A whole host of medications followed, the so-called typical antipsychotics or first generation antipsychotics. more common ones still frequently used (but not as much as 10 years ago) in psychiatry are Haldol, Prolixin, Navane, Stelazine, Loxapine, Mellaril. They treat psychotics symptoms such as hallucinations, (seeing things that are not there, or hearing voices of people that are not there) and delusions, false beliefs not grounded in reality (eg. the NSA planted a micochip in my brain and is monitoring me or I have a special power in that I can predict the future, or I am Jesus Christ) Delusions can be different types, paranoid or grandiose for example. Some people act on there delusions or hallucinations. Sometimes hallucinations tell people to hurt or kill themselves or hurt other people. The antipsychotics attenuate and sometimes take these symptoms away completely.These kind of symptoms are seen in people suffering from schizophrenia, schizoaffective disorder, and sometimes severe bipolar disorder or severe unipolar depression.

The first generation antipsychotics also have a host of potential side effects.

The most severe one in the sense of it being permanent even if you stop the medicine is called tardive dyskinesia. This is a movement disorder, that involves repetitive stereotypical movements, that are not controllable. Such as lip smacking, crossing and uncrossing ones legs, or finger tapping. The movement disorder doe not keep the person from sleeping and often it is more distressing to watch than for the person afflicted with it.

A second generation of meds was developed in the late 1980's and through current day. That is the so called atypical antipsychotics or second generation antipsychotics, these meds are much less likely and virtually some not at all likely to cause tardive dyskinesia.

They are generally much better tolerated by a person than first generation meds. They tend to cause much less apathy and bluntedness. In fact they often improve those symptoms which are seen in people suffering with schizophrenia. So you see another problem with the first generation meds was that some of the side effects, sluggishness, apathy for example were also symptoms of the illness of schizophrenia.

The second generation meds, main problem which class action law firms have jumped on suing the drug companies for is the association of these meds with the possible development of type II diabetes. That becomes a hotbed of political and economic controversy. It is often poorly understood by other areas of medical specialties outside of psychiatry.The second generation antipsychotics are Clozaril, Risperidone, Zyprexa, Seroquel, Abilify, Invega, and most recently Saphris. They were considered antipsychotics but most of them have been approved and indicated by the FDA for various phases of bipolar disorders. So they are not just considered second generation antipsychotics anymore.

The government body the FDA puts out a warning on these meds but does not pull them off the market, the warning is called an ASSOCIATION of these meds with the possible development of diabetes. Accordingly proper periodic blood monitoring is required, to check a fasting blood glucose for example. Its a quandary because type Ii diabetes is growing so fast (on or off these meds), but it has created much opportunity for some lawyers. It is sort of like suing McDonald's for spilling there hot coffee on yourself and burning yourself, or suing the fats food chain because you got fat and developed diabetes from eating french fries. It would be easy if these meds clearly caused diabetes and were considered unsafe then the government could just pull them off the market. The truth of the matter is these meds no matter how much we hate them or hate psychiatry have helped a lot of people and saved many lives. That part gets missed. And no it is not as simple as money changing hands with the government or the drug companies and there profits. If it was that simple things would be easier. and no doctors do not get kickbacks to prescribe. It is amazing how many people assume that. Don't you think with how vilified physicians actually are in society it would be a little more apparent if it was that simple?

The truth of the matter is at this point these types of meds are the best we have right now, and most doctors that prescribe them are not doing it for fun or experimenting, they are actually trying to help their patients. How does that point constantly get missed? i know why it does but it would take a book to write about it.

CerafolinNAC- a medical food

2010-02-26T15:15:00.000-08:00

FDA approved as a medical food. for the treatment of early memory loss including Alzheimer's disease. This has to do with vitamin B-12 and Folate which we have all heard of. In fact when a doctor does a workup for Dementia one of the reversible causes of dementia is a deficiency in these vitamins. It is treatable, that's why it is considered reversible, clinically it looks a lot like Alzheimer's. This is some of the blood-work the doctor orders when doing a dementia workup. Now people that have enough and normal levels of these vitamins still get Alzheimer's. Taking extra amounts of these vitamins does not stop or cure Alzheimer's. But it does show some promise in providing some cognitive benefit.

Much of the issue of B-12 and folate and cognitive decline has to do with metabolizing homocysteine. elevated levels of this amino acid are seen in many Alzheimer's victims. The reason, cause and effect etc is pretty interesting and a current area of research. I will discuss this more in future posts.

CAREGIVER EMOTIONS

2010-02-23T13:58:00.001-08:00

Generally they run the gamut. first of all depending on what stage your family member is in, this will dictate some of the feelings. They tend to vary and have a significant range, sometimes for no apparent reason and sometimes for a very good reason. At the two opposite ends of the spectrum are HOPE and UTTER DESPAIR. They are intense and strong, it is unusual to have a mundane day. There is the psychological issue of coming to terms early on after the diagnosis, and knowing and accepting there is no cure-that can be mentally exhausting as is any grief process. Mental overload and exhaustion leads to anger, sadness, anxious feelings and sometimes physical symptoms and problems, more headaches, irritable bowel, aches and pains, back problems, neck problems, lots of signs of mental stress, the physical complaints are really, the stress on the brain stresses the body, the immune system is weakened etc etc. Throw in the fact that Alzheimer's caregivers don't really have too much time to take care of themselves, not getting enough sleep, not eating right etc etc and you have symptoms compounded.

Then there is the actual physical exhaustion, staying up all night, perhaps trying to balance a full time or (more than full time job), raising your own kids or grandkids, and then caring for a loved one with Alzheimer's is a set-up for overload. The physical exhaustion leads to more anxiety and feelings often of depression, not to mention the fact that when you actually CAN get a few hours of sleep you may be so anxious and frustrated over caring for you loved one and the hopeless and helpless feelings that often pervade, you actually can't shut your brain off and let yourself sleep.

Sometimes it is hard to slow down, throw in all the appointments you have to keep for your loved one, in addition to all the other aspects that go into balancing a modern american family- other relationships suffer.

Does it have to be this way? Where do you draw the line? How do you break the cycle. Are there some happy caregivers filled with hope, maybe even joy? There are, maybe far and few between. Hope and joy often tend to come in snippets. They are easy to miss if you can't slow down a bit. There is no one secret..........

California Chronicle Book Review

2010-02-20T09:57:00.000-08:00

Below is a link to Norm Goldman's review of When Can I Go Home? from California Chronicle website:

http://www.californiachronicle.com/articles/view/141187

Is Alzheimer's A Mental Illness?

2010-02-18T23:10:00.001-08:00

This is more of a political question in many ways than a scientific one. When we speak of a psychiatric disorder we often use the term "functional" as opposed to "medical". Functional essentially means without an organic cause.

We know that AD has a specific course, with specific and non-specific signs and symptoms. It has demonstrated changes in the brain at a microscopic cellular level as well as a macroscopic level when it is advanced. The gross brain of a victim with advanced stages of AD looks different than the gross brain of a person without the disease.

In many psychiatric disorders you can not find the physical changes in the brain. That does not mean they do not exist, it is just that science has not caught up in certain psychiatric disorders.

For a long time when AD was first becoming known in our conscious awareness some twenty or so years ago, the issue of a psychiatric disorder or not was a hotly contested and emotional issue by many advocates and groups. It really stemmed from the fact that we have terrible biases and stigmas associated with mental illness. In fact we still do. We did not want to classify our AD victims with 'those' kind of disorders.

In fact there are many psychiatric disorders where you can find differences in the brain. It is well-established that people suffering with schizophrenia for example, have larger ventricles in the brain compared to people without schizophrenia.

The debate was further compounded by the fact that the Diagnostic and Statistical Manual (DSM) which is still on its 4th edition and goes back to the early 1950's in the first edition, lists Alzheimer's Disease. This manual is sort of the "Bible" of psychiatry developed by committees of experts that have time, and published by the American Psychiatric Association. It lists diagnosis and criteria to make the diagnosis. It has two actual practical purposes besides academic (and political). lawyers and judges love it, in a court of law, because it is in black and white and considered dogmatic, and insurance companies like it because they recognize some diagnosis of which they will actually reimburse for.

Many people do not like that Alzheimer's disease is listed in the DSM.

The fact of the matter is there are many personality changes and behavioral changes in AD. A victim can develop depression or display irritability, aggression, or speak in a delusional fashion (for example become paranoid) and even develop hallucinations- seeing or hearing things that are not real.

These are all signs and symptoms we generally reserve as conventional psychiatric symptoms.

Sadly we really don't treat our mentally ill with much respect or dignity in our 21st century world. The stigma abounds. It is not unlike how society stigmatizes AD, whether we want to admit it or not.

As families we often don't like it when the psychiatrist gets involved in the treatment of our loved one with AD. The psychiatrist is usually associated with the prejudices we have about mental illness.

In the end the question is irrelevant. Mental illness is real and people suffer with it, just like AD. both need to be treated and they both need to be treated with more compassion, no matter what way you look at it.

Euthanasia, Suicide, Death Panels, Dementia, Sir Terry Pratchett

2010-02-12T12:37:00.000-08:00

There has been quite a bit of buzz lately about expediting death in the event of Alzheimer's.
There are a few good reasons for this.
1. Consider the fact that Alzheimer's is now a household word. Most people in America and the Western World have heard of the disease. (see earlier blog posts)
2. Then in the United States throw in the current health care debacle. There is not enough money and resources to go around. Everyone needs health care, it is a right, NOT a benefit, hwo is going to pay for all this, the Democrats don't know what they are doing, the republicans don't care, etc etc etc.

It's so political.

Then we keep hearing about 'LIMITED RESOURCES' hmm, we don't have a cure for AD, the treatments are of limited efficacy.

Alzheimer's patients can't speak up for themselves too well. Families are too busy trying to survive and care for their loved ones with the disease.

so what the the head scratching and problem solving lead to?

Well lets go back to the old death with dignity debate. Everyone is scared of getting the disease. There is a little less shame around it. So we have more noteworthy people and families, celebrities talking about it.

Perhaps we should revisit assisted suicide, with limited resources and all.

I had a comment on a post the other day on Huffington Post about this very topic.

If a person with Alzheimer's forgets to eat the food in front of them is it time to die? The original article hinted that no nutrition may be a painless peaceful way to die.

Except it is not.

It sort of hurts to be starving to death even if you have Alzheimer's.

Now I am not being unreasonable here, I do not believe in IV's and insertion of feeding tubes when a person is at the end stages of Alzheimer's disease. But through most of the stages, a person with Alzheimer's still has feelings, right? They may not be able to cognitively express them.

Sometimes I think some of us worry about our pet's feeling more than our elderly. Of course the politically correct term for decades now has been "seniors".

We make fun of the elderly, we say "oh I was having a senior moment" the young and youthful often joke about Alzheimer's- as if they might never grow old.

We are at the point of abolishing the word "retarded" in our vocabulary, it is considered mean and very politically incorrect, we would not dare pick on a special needs child, or a person with a developmental disorder.

Do we pay that same respect, that politically correct carefulness to our elderly? -Maybe.

emerge Sir Terry Pratchett, one of the most famous best selling writers in Great Britain. He has AD. He donated a lot of money to Alzheimer's research. He does not want to live through the stages, and envisions a more romantic way to die.

I suppose that is his choice.

Here is my fear, what if a young cool person, with no medical problems has a living will-really clear nice advance health care directives. They decide that if they get Alzheimer's and the first time they forget to eat, they would like to be put to death. A Facilitated death. Suicide. Perhaps by not putting any food in front of the person anymore. A passive facilitated death. -Or scary thought, a more active facilitated suicide.

Fine good, progressive thinking right? Totally Hip.

Well what happens when that living will, advance directive comes into play, and it just so happens that the person with moderate dementia, that forgot to eat, changes their mind. What if they now want to live? No one will believe them- they are not of sound mind and competence. They can't give informed medical consent. Perhaps the family could override, but what if there is no family or legal guardian. Then the state takes over,

"too bad Alzheimer's victim, you said you wanted to die, we have no resources and you are a drain, it does not matter if you want to live now. We have your advance directive written when you were competent."

Does anyone see or care where this is going?

Who gets to decide? Some judge? A Panel of medical ethicists?

Euthanasia means "painless" death incidentally.

I am not particularly hysterical, but stranger things have happened.

And what about all that "end of life counseling" doctors would be given incentives to provide. Wow. We have not heard much about that lately, but it will be back I am sure. With the limited resources and all.

I wish there was more buzz about cures and effective treatments, rather than killing our old people with AD, couching it in some vogue, elitist, intellectual debate. some cultures actually still honor their elderly, not the norm in the narcissistic youth and beauty driven western world.