Why You Treat Me Like a Dog?: The Whims of Memory

Monday, December 05, 2005

The Whims of Memory

Doctor Bean and I share a patient who recently was admitted to the hospital because she passed out at home. She is a lovely nonagenerian who has heart disease that would require open heart surgery to fix, and she is too frail to go through with it. She has some memory deficits too, but usually keeps it together pretty well. Her first day in the hospital, she insisted she was at Lenox Hill Hospital (a hospital in Manhattan, New York) when in fact she was hospitalized at one of the local hospitals here in Southern California. Several days after being hospitalized I asked her about it and she chuckled, telling me that it was strange she would think that and that she knew she was at the hospital in California. I asked her if she remembered my name, and she couldn't. I then asked her where Lenox Hill Hospital was and she replied, "oh doctor that's on Lexington and 78th." I then asked her if she knew where Mount Sinai Hospital was and she said, "everyone knows that's on 5th Avenue and 102nd Street." She has lived in Southern California for decades.

Another one of my patients, a lovely octogenerian woman came to see me today because of a skin rash she developed possibly from a new medication I prescribed. Blanche (not her real name) is a feisty one who's losing her memory. She has blocked arteries in her heart, but we never did anything about it because she would have chest pain every once in a while, but would never remember it after the fact - so it didn't bother her too much. She comes to see me with either her daughter and her caregiver and I make adjustments to her medications and she leaves. I had told her once that my wife and I were expecting a baby and when he arrived, Blanche immediately dubbed him "The Chochem" (smart one in Yiddish). Every time she sees me since he was born four months ago the first thing she says to me with a big, partially toothless smile is "How is the Chochem?" Do you ever have chest pain, Blanche? "No doctor, I don't think so."

Serge Zweibel was one of my first patients when I became a full-fledged cardiologist. He was almost one hundred years old. In the 1920's he had played on the Czech national soccer time and was always an accomplished athlete. He survived the Holocaust and moved to America after the war. He remained very active for years until he was crippled by severe heart disease and arthritis. His mind always seemed crystal-clear. In his last few months of life he was repeatedly hospitalized with terrible heart failure. As he would gasp for air the first few hospital admissions, he would complain about his back pain and yell at the nurses caring for him. Once the medications cleared his lungs, he would invite me to sit with him, and he would tell me about his days as a star soccer player. He showed me pictures of himself in his twenties flying through the air kicking the ball spectacularly. We never talked about his experiences during the Holocaust. He would get a little better and then go home, only to return to the hospital a few days later. With time, he would ask me why God was doing this to him. He said he could not understand why God would let his body fall apart, especially his, the star athlete, and yet leave his mind so crystal clear that he would have to know everything that was happening to him. He would say that he wished he could be demented, and then at the very end, he would ask me to leave him to die and not treat him. I would cajole him to let me clear his lungs again, and he would let me, until the last time.

Elie Wiesel's book The Forgotten deals with the theme of memory and the Holocaust. The main character Malkiel Rosenbaum is watching his elderly father, Elhanan, a Holocaust survivor slowly lose his memory. Elhanan is very troubled by his memory loss. Like many Survivors, since his survival his raison d'etre has been to bear witness. As he feels his memory slipping away he feels extreme anguish. Malkiel must travel to Romania to vist his father's old village and revisit the places and events that comprise his father's memory. In the end Malkiel decides: "I will bear witness in his place; I will speak for him. It is the son's duty not to let his father die." Memory becomes existence, and existence memory.

In my day to day work I see many elderly patients, occasionally with cognitive impairment and varying memory deficits. On the one hand many of them seem quaint and "forgetful." It is easy to see them how they are now, and for me to forget that each of them carries a lifetime of memories. What is amazing to me is what actually sticks. What is it about a memory that makes it so significant that a person carries it with them. Why do some people remember a street corner from many years ago, can remember a newborn "Chochem" from four months ago but can't remember a noxious sensation or a painful time in their life. One can talk of "selective memory," and perhaps that each person chooses what to remember. There are some things that just can't be explained, and instead it might just be enough to observe them and then take some free time to think about them a little. Maybe that's how memories are formed - we remember what we think about, and we think about what's important to us. And different things are important to different people. I guess today, thinking about memory just seemed important to me.

- posted by wanderer @ 8:21 PM

Comments:

Beautiful. I linked.

# posted by

Doctor Bean : 12/06/2005 9:51 AM

Ditto to what Doctor Bean said.

I have always been fascinated by memory, having volunteered for several years with geriatric patients. The short-term memory barely sticks around for patients, and it's those long-term memories that ensnare them and often captivate their listening audience.

Thanks for sharing your experiences/insights.

Nu, so how's the Chochem?

# posted by

torontopearl : 12/06/2005 10:12 AM

Hmm... Your comment about selective memory, or what we "choose to remember" is interesting... Recently I've been thinking about the same thing, and thought that maybe it's retrieval of memories that is selective. If so, why? I was talking about someone I knew a long time ago, for the first time in years, and suddenly remembered a comment someone else made about that person in a conversation we had when I was just seven. Obviously, I long since forgot about that particular comment because it was so trivial, and all of a sudden it, of all things I could remember about that person, came up! But of course, I have no idea what happens when one starts having serious problems with memory... Both could be affected...

# posted by

Irina Tsukerman : 12/06/2005 11:50 AM

DB - thanks for the link! I'm wondering though if you'd consider any post that starts with the words "Doctor Bean" beautiful... ;)

TP- thanks for stopping by - welcome! The Chochem is doing well, sleeps through most of the night but likes to share his singing voice every morning at around 5 AM... Talk about forming memories - I will always remember his operatic arias!

Irina - thank you for your comment. I agree with you. I think we are probably hard-wired to remember everything, and we are in fact selective about what we retrieve down the line. Perhaps that's why procedures like hypnosis can help uncover suppressed memories or certain events can "jog" us into remembering things out of the blue.

# posted by

wanderer : 12/06/2005 3:40 PM

This was beautiful. I have spent a lot of time thinking about memory and I truly believe that the events and people we think about the most become committed to our long-term memory, where they are with us for the long-haul and everything else just stays briefly in short-term memory.

# posted by

Stacey : 12/07/2005 3:08 PM

Got here from Doctor Bean's link. This is really beautiful and hits close to home for me. My grandfather suffered from dementia for 4 years, but when the grandchildren and great-grandchildren came to visit, he would always perk up. Many times he did not remember who they were. He had always loved to sing and was a part-time chazzan, so we always had the kids sing "his" songs and then it was like turning on a light. The familiar songs brought him back to us for a short while.

# posted by

Anonymous : 12/08/2005 6:34 AM

This is a very touching post. As a PCP, I value long-term relationships with my patients. About 10 years ago I started to see a woman in her 70's who was a sculptor. June was still active, getting commissions from museums and public works to do bronze statues. She often would bring in pictures or paintings for me to see, and I was always happy to show off the latest piece of artwork from my young artists at home. She was divorced, witty, sometimes stubborn, but always a pleasure to chat with.

About a year later she developed atrial fibrillation and we hospitalized her and placed her on blood thinners and appropriate medications, and she did well with that.

A few years later she came to me complaining that she was having some memory problems. She did well on a mini-mental status examination, and I tried to reassure her. I think I was trying to reassure myself as well.

Over the next few years, it became obvious that she was forgetting more and more. She was getting lost on the way to my office, forgetting where she placed things like keys and bills, and starting to get moody. Her daughters became more active in her care and eventually started driving her to her appointments.

I made myself available to one daughter via email, and had a closer view of the situation that way. It was clear after a while that she was developing dementia, more likely due to mini-strokes than alzheimers. Although we tried some alzheimers meds anyway, but they just made her agitated.

I sent her to a dementia specialist who initially told her she did NOT have dementia. I found this hard to believe, since I had known her for several years by now and could clearly see the changes.

It didn't matter, because with in a few more years it was obvious that she was suffering from advancing dementia. She was having poor judgement at home. She allowed some unscrupulous art dealer access to her collection and he almost swindled her out of house and home. She became more paranoid and started calling her daughter in the middle of the night about non-existant prowlers.

She started leaving the range on and forgetting about it. It became obvious that she was unsafe at home. She had worsening mood swings. We tried various medications, which seemed only to accentuate the situation. Eventually she was hospitalized and placed in a nursing home.

It was extremely painful for me to see her there. I could tell that she was totally disoriented, out of her element, without familiar landmarks, despite the paintings and personal items her daughters brought there. I had always thought it interesting that, even though she didn't recognize her daughters, she always knew my name. After a while, that ended as well.

Soon she could do nothing but babble. No meaningful conversation could be had with her. I saw her, month in and month out, and it was extremely difficult for me. I still remembered her as the feisty, intelligent, and extremely talented woman who was still in high demand for her work by the various institutions around town.

To see her babbling, in a diaper, with a feeding tube which had to be concealed so she wouldn't pull it out, was just terrible to me.

She did eventually pass on, and I think it was a blessing. For all of us who knew her, she had died years before.

Her daughter brought me a little statuette from her mother's collection. It is of a woman with a sack of vegetables slung around her waiste. I am looking at it now as I type this.

This is who June was, and when I look at the other demented patients at the home, I have to remind myself that these were once people who may have had much to contribute in their prime, and always deserving of my respect and best efforts.

# posted by

PsychoToddler : 12/08/2005 9:59 AM

Stacey - thanks for your comment, and for stopping by!

Essie - its amazing how music can do that isn't it? It's clear that its a different part of the brain involved with music, and perhaps that part is not damaged until later in the course of Alheimer's. Thanks for the visit.

PT - Thank you for sharing that story. I guess all physicians have certain patients that just touch them in a certain way. Its very sad and difficult to witness a previously vibrant patient's decline. I think its part of the honor of caring for people that we are enriched by them as much and sometimes more than we enrich their lives. I try to remind myself of that every so often.

# posted by

wanderer : 12/08/2005 11:17 AM

What a beautiful story. You have a great gift for pulling the best out of a heart wrenching job...

One of the things I could kick myself most for is not having talked to my grandparents more. I am the youngest of 8, as was my mother. My grandmas both had fantastic, vibrant memories of long-gone times(I'm 35, yet both of my grandmas were born in the 19th century). They were alive when I was a teen, but I was a typical stupid teen. I never talked to them.

(*)>

# posted by

birdwoman : 12/09/2005 5:35 AM

For all of us who knew her, she had died years before.

PT, so interesting that you say that. I had said the same thing about my grandfather.

# posted by

Anonymous : 12/09/2005 8:15 AM

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