dementia diagnosis
If one is a geriatrician, a good part of one’s practice is focused on individuals either living with dementia or concerned about having symptoms that might be dementia. It is often a frightening prospect, at times more so for the family members than for the person with the symptoms, depending on their awareness of the problem and insight into the implications.

As I looked through the health record, I saw the neuropsychological report that supported my initial clinical diagnosis of likely dementia. The symptoms suggested it was probably a type of Alzheimer’s type. There was a note that my secretary handed to me from the patient’s spouse which reminded me of many requests I have received over the years from family members accompanying a loved one to such a medical visit. She did not want me to share an adverse diagnosis with her husband.

Years ago, families and physicians sometimes conspired to withhold the true nature of a patient’s condition. As a result, patients and families were denied the opportunity to honestly express their important thoughts and feelings to each other before the patient died.

Gaining trust

What should I do about this latest request? I looked again at the wife’s note and asked the couple to come into my office. I knew that I would have to gain the couple’s trust to ensure our future relationship would be productive. After our initial greetings, I turned to the issue of the neuropsychological report. “So how did that go?” I asked the patient. “I think pretty well. What was the result?” he replied.

I responded that the reason I sent him for the examination was because his wife and I had concerns about his memory, and that I suspected dementia. I could see the patient tense up when I used the term dementia. I continued, “You know that we use the term dementia to mean something is not right with the way the brain and its ability to remember things works. There are many disorders that can cause dementia…”

Breaking the news

The patient concentrated on my every word. I continued, “Fortunately, we now have medications and other treatments that can treat these conditions, including Alzheimer’s disease.”

I want to try one with you and start it now at a low dose to give you the best chance of tolerating it until I see you in a few weeks for follow- up. Is this OK with you?” I could see his wife with a bit of trepidation waiting for his response. “Sure…are there any side effects?” he asked. I replied, “Most people tolerate the medication well but I always start with a small dose just to make sure.”

As he got up to leave with his prescription, I said that I looked forward to seeing him. I did not tell him or his wife what to expect so that there would be no pre-conceived ideas of his treatment. As she left the room, the wife said, “Thank you, I did not believe we could do this and we did.” I’ve learned through many years that open and honest communication between doctor and patient (and their family) is more helpful than avoiding the truth. It has to be done with sensitivity and sometimes over time rather than in one meeting.

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Dr. Michael Gordon MD, MSc, FRCPC
Dr. Michael Gordon, MD, MSc, FRCPC and FRCP(Edin) is medical program director of Palliative Care at Toronto's Baycrest Geriatric Health Care System and professor of Medicine at the University of Toronto. He an educator and author and is involved professional and public education. An American by birth, he is a graduate of the University of St. Andrews Medical School in Scotland. His pre-specialty training included Internal Medicine, Obstetrics and Gynecology and Nuclear Medicine. He came into geriatrics in Canada where he settled after much world-wide travelling for his medical training in 1973. He came into geriatrics by a confluence of unpredictable events prior to it being recognized as a medical specialty in 1981 at which time Dr. Gordon received the first certificate in Geriatric Medicine awarded by the Royal College of Physicians and Surgeons of Canada. His career has included a wide range of clinical activities in eldercare, which for years included responsibilities at Toronto’s Mt. Sinai Hospital. His main commitment has been to the Baycrest Geriatric Centre where he served for many years as its Vice President of Medical Services and Head of the Department of Geriatrics and Internal Medicine. He currently devotes his clinic and administrative and educational activities to Geriatric out-patient care, in-patient palliative care, medical ethics and end-of-life planning, communication and care and writing for the lay and professional press. His books include his first book Old Enough to Feel Better: A Medical Guide for Seniors which went through three editions; An Ounce of Prevention: A medical guide for a healthy and successful retirement; The Encyclopedia of Health and Aging; Parenting your Parents (two Canadian and one American edition); Brooklyn Beginnings: A Geriatrician’s Odyssey; Moments that Matter: Cases in Ethical Eldercare; and most recently Late-Stage Dementia: Promoting Comfort Compassion and Care and now the revised third edition of Parenting your Parents: Straight Talk about Aging in the Family. For more information see drmichaelgordon.com

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