A visit to the neurologist often reminds me of stepping up to ride the tallest most twisty ride in the park. You start off slowly inching along, anticipating a thrilling experience with just a hint of fear. Then the bottom falls away and down you go. Sometimes the ride is exciting, everything you expected. Often the anticipation and hype don’t live up to your expectations.
Do We Expect Too Much?
Gary just finished with his last neurology visit for this year. We’ve had an outstanding year as far as finding solutions to some of his problems. We’re lucky to have been assigned an indulgent doctor who listens to my oft-times long-winded list of concerns. I am aware I can be a high maintenance caregiver at times, but without constant prompting, Gary often rambles through triage sessions.
Why does it always feel like it’s never enough? Superficial siderosis is a slowly progressing condition early on, but there seems to be a point of acceleration that is alarming to witness. 22 years passed before symptoms became disruptive to our life. Now every new event seems magnified.
You arrived at your appointment with a list of changes, and it hits you in the first few moments your rotating resident hasn’t bothered to read the file very thoroughly.
“So Mr. Daniel, you’re here about headaches?”
” No, he’s here because he has superficial siderosis.”
“You have a problem with your lungs?”
*I am now silently slamming my forehead against the imaginary wall in my mind.
Fast-forward ten minutes when my memorized lecture on superficial siderosis is finished to where we begin to discuss Gary’s changes. Now from a medical standpoint, I understand not every symptom change is critical but I’ve learned in the world of VA it’s better to start tracking changes via Gary’s healthcare provider written notes so when circumstances do become extreme there is a trail. Every symptom we brought up was met by a look of wonder. That too? Our resident decided he’d better start reading.
Gary’s short-term memory has been rapidly changing for the worse in ways that have been painfully obvious to those around him. We met a couple in the grocery store we’ve known for years. Gary couldn’t remember his friend’s name. He knew his face, and he knew he should know him, but his name was gone until I prompted him, “Hi Bob, where’s Linda?” This glitch stood out because for the first time it wasn’t short-term memory that failed. Gary’s long-term memory has always remained extremely good.
Our resident had Gary go through the Mini-Mental State Exam (MMSE). Gary has been given a lot of these type of tests over the years. Most often they use the Saint Louis University Mental Status Examination (SLUMS) for signs of early onset dementia. My complaint? The MMSE is not sensitive to mild cognitive impairment. Gary has zero problems copying blocks or clock faces. Scoring a short-term memory exam seems extremely skewed when your resident provides excessive word prompts and clues.
Resident: Mr. Daniel, can you repeat the five words I told you earlier?
Gary remembers two words.
Resident: The next word was a color. It’s bright. The color of a fruit you eat.
Resident: Can you name me the flower I said?
Gary: Yes, the word was “flower.”
Resident: No Mr. Daniel, it was a flower. It’s white. Children collect them and make chains.
Resident: Perfect Mr. Daniel! Can you repeat the last word? It’s a place you go every week. A place you go to pray.
The resident never bothered to ask the names of the three animal pictures he showed him earlier. He just scored them as correct.
In the four years since Gary’s been taking these type of in-office tests, he hasn’t scored higher than a 21 in recent years. The resident scored Gary with a 27/30. How nice Mrs. Daniel! It looks like your husband’s memory is getting better!
Wonderful. I’ll be sure and tell Bob.
Two Steps Forward One Step Back
Our discussion with Gary’s neurologist was a little more productive despite the resident’s rosy assessments and pencil whipping unperformed tests. Gary will be scheduled for a GI motility test soon. His visit with the otolaryngologist suggested his increasing acid reflux and weekly bowel movements were the results of poor gastric motility. His increasing lumbar pain was moving into the intolerable stage so first up will be physical therapy three time a week. If physical therapy can’t provide some relief, then a pharmacological route will have to be explored.
The walker is moving up into the line-up more and more with Gary’s worsening balance and gait. His PCP has an appointment scheduled for us to pick-up a wheelchair this January. At this point in time, the wheelchair is more for cardiac-based endurance issues rather than ataxia. Gary still has excellent muscle strength and tone.
Other negatives for this year besides the balance and ataxia issues is in spite of two different models of hearing aids this year his hearing is getting markedly worse. His audiologist doesn’t want to visit a cochlear implant unless it’s the last resort.
Even though Gary lost his sense of smell along with the ability to distinguish flavor a long time ago, his five basic tastes that come from his mouth and tongue are now disappearing. Salty is still pronounced as is sweet but the others have begun to fade. Our most pressing concern is getting his lower back pain under control. Sitting, standing, or riding, the pain is always there.
Positives for 2018 include getting the horrible headaches under control using Greater Occipital Nerve blocks. Gary is injected with a mixture of 2cc 0.5% Marcaine and 1/2cc Kenalog 40 Mg/ml four times a year now. He still has headaches, but they are more typical in duration now. The traditional Chinese herbal medicine is still keeping the burning pain in his feet under control though he still suffers from ice cold extremities at times.
Neurology is now transitioning Gary into a status of stable for now. We will only return every six months. We’ll continue to make the rounds between multiple specialties.
Here’s hoping for more positives in 2019.