Togetherness

I see a patient and the patient's wife (and her Mother) are also patients. Today I saw both the patient and the wife-patient. Soemtiemes it works like that. I actually have several married couples that are both patients at the same time. It comes with the territory of working where there are many elderly who tend to have lots of neurological problems. This particular couple isn't that elderly, though.
The wife is lonely. She doesn't really feel close to her husband.
The husband is lonely. He doesn't really fell close to his wife.
They both wish that they could be closer to each other.
One had a stroke, the other has migraines.

I'm so used to seeing people who are lonely because they are alone that it is a challenge to care for people who are lonely even when they are together. There are many widows and widowers in my practice. I suppose that some of them were also lonely when they were together. It takes a great skill and acceptance for the people who are together to avoid being lonely. This is very true when one person has a serious illness. It is even more true when a person has a stroke when they are young. It is not expected. There is such great disappointment. People get hurt and they get angry. Life isn't really fair, but when it isn't fair to you, it's upsetting.
I tried to get them to be alittle bit closer today. I don't know if it will work or not. Sometimes we have to try different things. We have to start with very small tasks and be satisfied with the rewards. Mother Theresa said: "There are no great acts. There are only little acts performed with great love."
So I told them to go for a little walk together every day and get a cup of coffee once a week. To some people that may not seem like a very good relationship. But for me, it would be wonderful. That's because right now they have much less than that. I just want them to take one step forward. One step forward is wonderful. Wherever we are, if we see where we want to go we can just go in that direction - we don't have to get there. It's not about getting there, it's about going the right way. If you have a stroke or get sick at a young age it can throw you in the wrong direction very easily.

Talking at Support Groups

I went to a diabetes support group this morning to talk about the diabetic complications of nerves - diabetic neuropathy and carpal tunnel syndrome and autonomic dysfunction. It was a very nice group. There are so many support groups that aren't good. They are "pity parties". Everyone goes there for the sympathy of the others who are also suffering. When people have feelings, they want "validation". That means that there is a need for someone else to understand. "Please understand my suffering." This makes it somewhat better. The difficulty is that if everyone sits around understanding everyone's suffering, it promotes that suffering in a way. It's important to get past that, though.
The support groups also educate people. Education, of course, is always good. That part I've always liked but it can be overwhelmed by the idea that it's OK to sit around and suffer because everyone else understands.
Whatever we're experiencing doesn't exclude a positive experience. We know this from Hospice people who are "enjoying" dying. Or at least who are dying with grace. We learn how to die with purpose and meaning. This is the key, I think, to illness. So support groups need to have an awareness of this. In this case, with diabetes: "It's OK to have diabetes."
This group had a sense of that. So it was uplifting to see that. It is OK to have illness. It's a part of being human. It is our nature to become ill. So we need to find a way to be OK with that. We need to accept this as a part of our humanity. In being "philanthropists" (lover of mankind) we need to encompass all of humanity within our capacity to love. That's also a part of that "for better or worse...in sickness and in health" thing. We love the person we married even though they may be human from time to time. We fall in love with them when we see their innner divinity. That's easy. Then, when we see their humanity we have to stay in love with them - that's the real trick.
We don't really get to see our humanity as well as we do when there is illness at any other moment. So it has to be OK to have illness.

"Dementia"

TR was here yesterday. He has complaints about memory loss. He is doing very well, despite his inability to remember things. On his Neurtrax, which is the instrument I use to measure thinking, he scores 104 which is just above average. Average is 100. One standard deviation below normal is 85, which is considered "abnormal" on the test.
We have a classification called "Mild Cognitive Impairment". We have "Normal". We also have the famous "Dementia". "Mild Cognitive Impairment" means (as close as I can translate), in English: "There's definitely something wrong, but it isn't bad enough to say that it's Dementia. We have guidelines set up to determine that someone has dementia.
The reality is that people "slip". They don't generally go downhill in steps. The slide one point (a made up point of some sort of unknown unit) per month. The course is a linear one. Although different people decline with somewhat different slopes of the line, there isn't a huge variation. Almost all of dementia is "neurodegenerative" which means either Alzheimer's or Vascular Dementia (many tiny little strokes) or a combination of the two. According to our current standards each year 10% of people with mild cognitive impairment develop dementia.
TR has been a patient of mine for about two years. When we started with his thinking he was 102 on the Neurotrax. That means he's had no change in cognition (he has a better score, but since it's only a couple of points that's basically "unchanged"). I have another patient who has had a somewhat larger increase in his score.
Most of my patients with thinking problems are on some sort of Alzheimer's medication. Very few of them can maintain or increase their thinking, though. So it isn't a matter of just the medications we're using. (I do think that Turmeric and Barcopa are especially effective, though). I know that there are some people with MS who can repair broken brain cells better than others. I suppose that's also true with the dementia illnesses. Unfortunately, no one has really written anything about these people who aren't "sliding". No one even seems to acknowledge that there can be people who are "climbing" instead of "sliding". I don't do research anymore, so I'm certainly not in a position to tell anyone what to do research about. It seems to me that this small group would be very interesting to look at. I want to know why they're doing what they're doing and how I get all of my patients to do the same thing.

It's kind of frustrating sometimes that we don't seem to know anything. Then it seems to me that the most important questions aren't even being examined very carefully.

Breakthrough

There's a "major breakthrough" in the newspapers this morning. Of course, there are only "major breakthroughs" in the media world. In reality, we learn incrementally. I've been in the medicine game for over twenty years. In that time, there hasn't been a single "breakthrough". Everything that we've learned (an incredibly enormous amount) has been a painstaking development of accumulated tid bits of information and hundreds of publications. Anyway, CRP is a protein that is not as famous as some biomarkers. It reflects a state of chronic inflammation which we know is probably an important part of what we now call "metabolic syndrome" which is possibly a pre-cursor state of diabetes versus a chronic "not healthy state" (that's my term). In essence, it's a sign of being an American: non-exercising and unhealthy eating. There was a study of 18,000 people with elevated CRP and normal cholesterol levels who were given statin drugs. There was a 50% reduction in the risk of heart attack and stroke. This isn't a huge surprise. There's been data on this published before. There is also data on reducing these cardiovascular risks by treating people with "normal" blood pressure with blood pressure lowering medications. The mediterranean diet and the effects of exercise, if they're additive probably have an equal effect. We seem to be getting relatively close to figuring out that it's good to be healthy. We are developing all sorts of medications to combat the poisoning that we're doing. Soon, we're going to be just as good at giving ourselves chemicals to stay healthy while we poison ourselves and neglect our well being as if we were just healthy. And we're also going to figure out that it's all a spectrum. The healthier the better. We "just found out" recently (in another "major medical breakthrough") that we can improve outcomes by treating kids with cholesterol lowering medicines. So we can start earlier and earlier. Treating CRP is just one step down the chain from cholesterol. It's a way of starting earlier, because 50% of people who have a first heart attack have "normal" lipid profiles. I think before I retire we'll start giving infants medication in their formula to fight off the effects of poor health habits. (Oh, wait. We do that already - it turns out that breast milk is better for babies, but we can avoid that healthy behavior, cause harm and then add chemicals!)
I try to get patients to exercise and eat right. But this is definitely not the American way. It's very hard in this culture to do that. We're not structured for it.