YOUR HEALTH: How to manage forgetfulness or dementia, By Dr Nkechi Obianozie

Dr A was a brilliant surgeon. He had worked for many years mentoring residents and training students, and he was highly valued in his department. He also had a sharp and ready wit, ready with the next answer and quick to respond to jabs.

He spoke English, Yoruba and Hausa fluently, although his first language was Yoruba. Everyone knew not to cross him in the department because he had a sharp tongue and would lash out with the most caustic retorts. As he was nearing retirement, he became the head of his department and was saddled with a lot of administrative responsibilities.

His secretary began to notice some lapses in his concentration about a year into his new role. He would forget his keys in the office and be looking frantically all over the surgical block. She also noticed that he seemed sort of withdrawn and less alert.

These changes did not go unnoticed by his surgical residents. He would appear distracted during procedures and his speed during surgeries had slowed down.

He would no longer chat and engage the residents assisting in the procedures. His wife also had noticed that Dr A was not his usual self. She chucked it down to the enormous responsibilities of the administrative work, but became alarmed when she returned from Omuguo in the US (their last daughter had a baby) and he forgot to pick her up from the airport.

When she returned to the house, Dr A was sitting in the parlour looking unperturbed and unbothered. She shouted, “Where the hell have you been, Taiwo? I waited for two hours at the airport, you were not answering your phone, and the gateman has been knocking on the door for hours after I called him to check on you?”

Dr A simply smiled and shrugged not offering any explanation. Mrs. A was convinced Dr A was perhaps distracted by too much work and the recent accreditation exercise at the department . She had been gone for three months and had expected Dr A to be excited to have her home.

The following day, she found Dr A searching through her handbag on the table top in the evening. On asking him what he was searching for he retorted “ I know you are coming from a hotel, I saw you leave the house at 10am and the gateman left one hour later, you must tell me where you people met up for your rendezvous.”

Mrs. A burst out laughing, “You must be joking T, how absurd?” A quick slap reset her brain, and she realised Dr A was serious. Very serious.

As the days unfolded Mrs. A knew that something was very wrong, her sharp Taiwo from UCH days was struggling to find his keys, the password of his laptop, and all sorts of small things. Together with his change in personality, she knew something was desperately wrong, being a nurse herself, she decided to seek answers from a close doctor friend.

As she began to recount the experiences, his memory lapses and behavioural changes, the reality dawned on her. Her worst fears were confirmed when the doctor did a bedside screening for memory and cognition. He told her, Dr A was suffering from early stages of dementia.

The behavioural symptoms were not uncommon and for some he said, were the first signs of declining cognition. As Mrs. A sat and cried in the office, she wept the loss of the man she knew. She knew all too well the effects of dementia and saw a road, long and bleak ahead of her. Dr A seemed unbothered, and the doctor explained that the apathy was also an effect of the brain changes. As she proceeded to Dr As’ office to clear out his things and prepare for a new phase in her life, emotions overwhelmed her. How would they cope? He was not due to retire till three years’ time. Who would care for him as he became more dependent? Her knees and back had seen the toll of many years of nursing practice, how would she tell the children, what did it mean for her as the primary care giver?

On reaching his office, she informed the secretary “I am here to clear out Dr A’s desk, he will be proceeding on retirement leave.” Deola, his secretary hesitated and then got up and gave Mrs. A a big hug, “Mummy, she said, I have been meaning to call you but Daddy said you traveled, Daddy is not coping with the job, there are piles of unsigned papers and documents on his table, people are beginning to talk.”

Mrs. A sighed, “ Why didn’t his best friend Robert tell me? Why would he allow things to get this bad?” Deola shrugged and said,” I don’t know Mummy, but I was going to tell you myself.” Mrs. A packed up his things and sent in his retirement letter. Dr A was neither sad nor happy at this decision, even more concerning.

This is the reality of many people struggling with memory and other cognitive issues, often lapses are noticed in the workplace, in social relationships but many look for other ways to explain them until they become so overwhelmingly obvious.

Dementia is a disorder in which there is a decline in cognition (which includes memory, executive function, attention, language, perceptual motor function, social cognition) that is significant enough to affect our activities of daily living. (DSM5)

The definition of dementia thus implies that a decline in cognition, which is not only memory. Cognition is defined as the mental action or process of acquiring knowledge and understanding through thought, experience and the senses. The brain uses various parts to be able to acquire information from the environment, store the information and then use this information to guide our behaviour. For instance, writing this article requires me to use my eyes to process what I am typing, my memory to recall information, executive function to be able to type and also check references, perceptual information to know how to place my laptop on the desk, attention for me to keep track of what I am doing and not be distracted by the multiple noises in the office.

It also requires my social cognition to know I cannot do this when I am having a work meeting or seeing a patient. All these are parts of cognition and what allow us to function as individuals in our various capacities.

Some types of dementia or cognitive decline affect more of social cognition, people behave inappropriately in some cases. For instance, you may not like your boss and think very unattractive things about him but your social cognition will prevent you from saying so or even expressing your distaste while he speaks with nonverbal cues.Dementia can also affect language, when people find it difficult to express themselves or understand spoken or written language, which of course affects our interactions.

Memory declines as we age due to changes in the brain, we are continuously loosing brain cells from the age of 30 but these usually involve things like forgetting names of people not so familiar to us, misplacing items, recalling conversations.

In most cases, the name or forgotten conversation later comes back to us. Age associated memory problems usually affect abilities to encode new information and retrieve existing information. However, what is key here is that one is still able to function, bathe, cook, clean oneself, do our banking, not get lost in familiar environments etc. These are what we term activities of daily living. If the memory or behavioural issue is affecting our ability to function then, it is termed a DEMENTIA

There is however a spectrum, what is normal for one person of high education and performance may not be for another. These subtle differences are often picked up by very educated people who feel their memory or attention is not what it used to be. They are functioning, but not at the same speed so to speak. These people may be termed after testing by the neurologist to have MILD COGNITIVE IMPAIRMENT. That is, there is an issue which is objectively identified but this individual is still functioning. For about one third of these people, these issues stay like this, about one third of them will progress to dementia, and another third will revert back to their normal state.

Dementia has no cure but there are ways identified by WHO to reduce the risk. Although some genetic factors are tied to dementia risk, about 40-65% of dementia can be prevented by addressing these risk factors. These include:

Physical health: Hypertension, high blood sugar, obesity and high cholesterol in MIDLIFE

Lifestyle: Physical inactivity, smoking, excessive alcohol consumption and poor diet

Sensory: Hearing loss and untreated vision loss

Mental : Social isolation and depression

Environment: air pollution and low education levels.

The brain should be thought of as a muscle which needs to be exercised, thus keeping active and good social relationships, learning more by continually stretching your brain to learn new things, taking care of your sight and ensuring your hearing are all ways to help prevent dementia.

Ensuring your blood pressure is well controlled, blood sugar levels are under control and your cholesterol levels are normal are also crucial in keeping the brain healthy for longer. Regular physical exercise is also protective for your brain.

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Hearing and sight checks should be mandatory yearly for all patients above the age of 65. If hearing is compromised, the use of hearing aids is strongly encouraged when indicated.

I often encourage my patients to join social clubs and communities as they age and retire, keeping active social lives, participating in town union and church activities, volunteering in nongovernmental organisations that they have interest in.

Screening for depression is also essential and proper management if identified.

Overall, keeping an active life mentally, physically and socially are important to help keep the brain as healthy as possible.

As for Dr A, he retired from clinical practice and continues to live life with his wife in a supportive environment. He was placed on donepezil which reduces the rate of decline in dementia and started on an antidepressant. A caregiver was also employed to assist in caring for him. Mrs. A has tried to maintain her own life and stay active. She continues to mourn the loss of the Dr A she used to know but accepts the man he has become.

Nkechi Obianozie, a Consultant Neurologist, is Fellow of the West African College of Physicians (FWACP)