7/12/18: MOM SUDDENLY EMERGES FROM SOME OF HER BRAIN FOG . . . I HAVE A THEORY; & A WORD ABOUT SUICIDE

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A wondrous thing has happened. A cloud has been lifted from my mother’s brain. The reason I believe this Oliver Sacks-“Awakenings” moment has occurred will surprise you.

The first glimpse of my 94-year-old mother’s altered state occurred two weeks ago on a Wednesday morning, when one of her caregivers arrived to find her sitting up in bed, surrounded by books, and reading.

This scene was extraordinary for several reasons. One, Mom has been sleeping until 2:30 or 3 p.m. every day, and still waking up tired; two, Mom has stopped reading anything more than the funny pages, presumably because she can’t remember what she reads, paragraph to paragraph, and she even forgets the funnies; and three, she chatted with Sharon, the caregiver, about what she was reading.

My mother does not have Alzheimer’s disease, but she has shown signs of cognitive impairment for years, chiefly problems with memory and executive functioning, such as decision-making and planning.

Awake, reading, and chatting? Not my mother. She long ago stopped conversing beyond simple monosyllabic responses: Fine. OK. Yes. No. And there are many days when her chin slips to her chest, and she nods off during dinner or during a television program—even after 15-16 hours of being in bed.

In March 2010, which was the last time that Mom allowed anyone to discuss her memory decline, she had a brain CT scan that showed, according to the interpreting radiologist, “mild cerebral atrophy,” “atherosclerotic disease,” and probable “microangiopathic disease,” which is a narrowing of blood vessels caused by the atherosclerosis.

Atherosclerosis is the primary underlying cause of vascular dementia.

I tried to have her evaluated at Eastern Virginia Medical School’s memory clinic, but, as I write in my book, “Our Parents in Crisis,” she “took one look at the cumbersome, unnecessarily detailed, multi-page questionnaire that EVMS sent for her to fill out before her appointment and said, ‘No way.’ And, besides, ‘my memory is not that bad.’ She tossed aside the paperwork and called EVMS to cancel. Needless to say, she never had a follow-up MRI.”

I accepted that Mom would never have a professional diagnosis. My physician father and I diagnosed her, for ourselves, with mild cognitive impairment (MCI) caused by cerebral atherosclerosis. In the years since her CT scan, Mom’s memory has worsened, but she needs help with “activities of daily living,” such as dressing and preparing food, primarily because of severe arthritis in her hands, not confusion.

When I take Mom to see her primary care physician for her annual exam, he asks her questions, but looks to me for answers. He accepts her cognitive impairment as par for the course for a person of advanced age, and the 2010 CT scan supports that belief.

***

“I couldn’t sleep, so I decided I might as well read one of these books that I have lying all around,” Mom told Sharon that extraordinary Wednesday morning.

With my mother’s increased preference for sleeping, the morning caregiver’s primary task in the past year has become figuring out how to get Mom out of bed.

“Ten more minutes,” she typically pleads. And then another 10 and another 10. I began negotiating with her: If you’re going to spend that much time in bed—which you know is not good for your body—then you’re going to have to do some exercises while you’re there and walk around more later in the house. You have to move.

My brother, who is also a writer, noticed the dramatic change in Mom that evening during his daily telephone call with her and documented their 30-minute conversation. Usually, Al just tells Mom what he’s been doing, asks her how she is and what she’s been doing—“Fine.” “Not much.”—says he loves her, and hangs up. Five minutes and done.

I also had extended conversation with Mom that night, during my usual two-hour visit, and tried to determine what had caused her transformation. I actually enjoyed my mother’s company, like I have for most of my life, instead of feeling that I was just there to look after her and get her safely to bed. I love my mother, but, on a given day, being her sitter and caregiver can cause me a lot of despair, especially now that Dad is gone.

I wondered: What had changed between Tuesday, when Mom was her old disengaged, confused, silent, and tired self, and Wednesday when the new Mom emerged?

One obvious change was Sharon, who’s her “fill-in” caregiver. Sharon took care of Mom Tuesday and Wednesday while Mom’s usual morning caregiver, Peggy, was having cataract surgery. Peggy and Mom have a loving relationship of nearly five years, so I knew that Peggy wasn’t harming Mom.

I asked Sharon about the medications she had given Mom. My father, who was a drug expert, taught me that whenever a sudden change occurs in a person’s physical well-being, mental health, behavior, affect, etc., you first should think about drugs. Is the person taking a new drug? Did the person forget to take a usual drug? What, if anything, changed with her medications?

Sharon had followed the medication instructions that Peggy left for her; no change there.

Mom told me that she hadn’t slept during the previous night. Had I forgotten to give her the sleep medication? Unfortunately, I had arrived Tuesday night for Mom’s bedtime ritual in a slightly inebriated state, and I couldn’t be 100 percent sure that I had given Mom her sleep medication.

I played it out in my mind 100 times: I could see myself handing Mom her pill, rather than giving it to her in a small glass bowl. I could feel my fingers touch her hand. But I couldn’t see her actually swallowing it. Had she dropped it? Had I actually not handed it to her? I had a shadow of a doubt. If only I hadn’t drunk so much wine!

After polling my three siblings, I decided to taper Mom off of her sleep medication and see how her brain functioned in a cold-turkey state.

To make a long story shorter, my trial didn’t show a cause-and-effect. Mom slipped back into her pre-Wednesday breakthrough state on Thursday and didn’t emerge from it until the next week when . . . Sharon came back for a day.

Aha! Sharon was doing something differently, and I thought I knew what it had to be. I almost eliminated this “factor” the previous week instead of the sleeping pill, but my younger sister asked me to hold off until after July 12, the date for Mom’s next blood clotting test, which Peggy handles. Mom takes the anticoagulant warfarin.

I couldn’t wait any longer. On July 9, when Sharon returned for a shift, I asked her: “How much coconut oil do you give Mom every morning?”

***

The coconut oil was not my idea. In fact, I had argued with my younger sister that we shouldn’t give Mom something for her brain health that hadn’t been proved in clinical trials run by reputable scientific researchers to be beneficial. But my sister had read online that coconut oil was therapeutic in Alzheimer’s disease and other dementia patients and might slow the progression of Mom’s cognitive decline. She wanted to try it.

Being one of four siblings, I yielded to my sister—I “pick my battles,” if indeed, this was one—and coconut oil became an everyday “enhancement” for my mother. Despite seeing no improvement in her cognitive functioning and, in fact, worrying that she was slipping away mentally, I did not discontinue the coconut oil. Not long ago, I discovered (through observation) that Peggy was lathering it on Mom’s toast and other breakfast foods, but Sharon never mentioned it in her daily log. So, last week, I asked Sharon: How much coconut oil do you give Mom? Her answer: Not much.

This past Monday and Tuesday, Mom ate no coconut oil, at my request. Yesterday, the “new” Mom returned. She was sitting up on the side of her bed, reading a book, when Peggy arrived for the morning shift. Peggy told me they had a wonderful day together, during which Mom chatted and even made funny comments. After Peggy filed Mom’s fingernails, for example, she told the caregiver that my dog Augie could have done a better job.

My siblings each had lengthy telephone conversations with her last night. My younger sister texted: “It made my day!”

Could the discontinuation of dietary coconut oil from Mom’s daily regimen have made such a profound difference in her affect and/or cognition in such a short time?

I’ll let you know. My clinical trial continues.

No doubt, you have heard and/or read all of the health hype about coconut oil.

It’s good for your skin, your hair, your heart, your brain, your digestion, your immune system . . . what else? According to the Harvard Health Publishing website, which provides “trusted advice for a healthier life” from the Harvard Medical School, there are “more than 100 recommended uses for coconut oil,” not all of them health-related.

Just what is coconut oil?

It’s a coconut derivative that is 90-percent saturated fat. Saturated fats have been shown to increase low-density lipoprotein (LDL) cholesterol, which is the bad cholesterol, and have been linked to cardiovascular disease—a connection that remains controversial. (See, e.g., https://onlinelibrary.wiley.com/doi/full/10.1111/nbu.12188.)

Do saturated fats “clog” arteries by contributing to plaque buildup? It appears to depend on whom you ask.

The Harvard Health Publishing article, “Coconuts: Heart-Healthy or Just Hype?,” cites a 2016 review for the conclusion that “. . . due to existing knowledge regarding saturated fatty acids and heart disease, evidence . . . suggesting that coconut oil raises plasma lipids and a lack of large, well-controlled human studies published in peer-reviewed journals demonstrating clear health benefits of coconut oil, frequent use of coconut oil should not be advised.” See https://www.health.harvard.edu/heart-disease-overview/coconut-oil-heart-healthy-or-just-hype.

I am sorry I ever signed off on Mom’s dietary coconut oil and am certain that, if my father were still alive, he would’ve prevented it. Whenever I suggested a therapy to him, he always answered: What is the evidence? What do the data show? That’s what he said if my idea got past his threshold laugh test. He was a master of biochemistry, physiology, cardiology, and other medical sciences, and I could rely upon him.

In the case of coconut oil, I now know, there are more data to suggest that it is heart-unhealthy than healthy, and not enough to support the belief that it is brain-healthy.

“If coconut oil is truly heart-healthy,” writes Dr. Robert H. Shmerling, a Harvard associate professor who is a faculty editor at the Harvard Health Publishing, “it would represent a major departure from the ‘limited saturated fats’ advice” of the American Heart Assn. and many other consumer-health groups.

The suggestion is that coconut oil can raise high-density lipoprotein (“good”) cholesterol and is high in “medium chain triglycerides,” aka MCTs, while most other saturated fats found in plant-based oils have more “long chain triglycerides.” MCTs are metabolized a little differently from other fats. Apparently, they break down into ketones, organic compounds that some have suggested are good for the brain.

But good luck finding a clinical study that shows dietary coconut oil can improve cognitive function in people with “normal” brains who do not have dementia.

I’ll give Dr. Shmerling, who is an internist and rheumatologist, the final word on coconut oil:

We’ll “need more and better research,” he writes, “to understand whether its newly found popularity is well-deserved, or just the latest flavor of the day.”

I know where I stand: Mom can eat chocolate instead.

Ann, 7/12/18

SUICIDE RISK: After the deaths in June of fashion designer Kate Spade and culinary adventurer Anthony Bourdain, it seemed that anyone who could write and get published was relating his/her own experiences with suicide. I have my own, the most poignant of which concerns the 2011 death of a law school friend of mine who jumped from the 18th floor of a high rise in Myrtle Beach just five days after I spent most of a weekend with her, trying to convince her to get treatment for her profound depression.

We were casual friends who had reunited in 2008 and saw each other every six months or so.  I did not know any of her good friends or any of her family members, in whom she told me she could not confide. Short of calling 911 and forcing her to go to a hospital emergency room, I did not feel that I had any influence over her—except by talking with me all night, she said she felt better. (She lived in Raleigh.) It was only after her death that I learned she had a history of major depression, suggesting bipolar disorder.

The reason I’m relating this experience is to say this: Everyone is a suicide risk. Everyone has the potential to kill him or herself, regardless of any opinions that he/she may have expressed on the subject or any answers that he/she may have given you when you asked the person if she was suicidal. All it takes is a moment. Just one step.

I didn’t see my usually optimistic, fun-loving friend as suicidal and, while I do not blame myself for what happened, I do wish I had done more.

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