Don’t say, ‘forget it!’ when you repeatedly forget. It demands brain imaging and some lab tests to see what’s messing with your memory—blood collection, tumor, thyroid, or simple B12 deficiency
A septuagenarian couple was seated in my consulting room. The wife started to talk as soon as she caught her breath. “He’s been forgetting a lot of things these days,” she complained. “He doesn’t remember what he’s eaten this morning or how much money he withdrew from the bank the other day.” She sounded a tad exasperated about taking care of him.
“Does he remember past events like which school he went to, his wedding date?” I questioned, hoping to give him some brownie points. “March 31, 1975,” he shot back, putting a gentle smile on her tired face. “He fumbles a little in his speech as well, I’ve been noticing.”
I asked him to close his eyes and stretch his arms out straight in front of him, parallel to each other with palms facing the ceiling as I demonstrated the action myself. After a few seconds, I noticed his right arm drift downwards while his left was able to resist gravity. I explained to them that this was probably owing to something pressing down on the left side of his brain.
“Do you drink?” I questioned innocently to postulate a diagnosis in my head. Husband and wife looked at each other and then at me. He shook his head sideways and she, up and down. “A few pegs a week doesn’t classify as drinking,” he reasoned.
I asked them to get a CT scan done right away on the ground floor, and within the hour they were back at the clinic. “It shows exactly what I expected,” I said with slight cocky arrogance, even though most of the time that I order a scan for forgetfulness, it usually comes back normal. “You’ve got a chronic subdural hematoma,” I stated, describing it as a collection of blood between the bone and brain and probably responsible for his symptoms. “You must have bumped your head somewhere without realizing it,” I continued, explaining that this can happen in the elderly even without any definite trauma. The brain atrophies with age and if a tiny vein between the brain and its covering (the dura) snaps, it can cause blood to accumulate over time and cause this symptom. “It needs to come out,” I concluded, even before they could ask how we should go about it.
The next morning with zealous quickness, we made two small incisions on his scalp and drilled two holes into the skull, a few inches apart, following it up with a cut into the dura. Dark altered blood emanated under high pressure. Although this is technically the easiest operation in our field and I must have done several hundred by now, I’m excited every single time I cut into the dura. With the delectation of a child, I’m eager to see what comes out. Each time the color of the blood has a varied hue of red, it jets out at a force that’s different every time, and the underlying brain is at disparate distances from the bone. I often joke with my dextrous orthopedic colleague that this is one neurosurgical operation I can teach him to perform because all it involves is drilling a hole into the bone.
After ensuring that all the blood was out, we closed in the usual fashion. The next morning, his absent-mindedness was gone, and at dinner, he was crisply responsive about what he had eaten for breakfast and lunch.
Dementia is a collective term used to describe various symptoms of cognitive decline. Forgetfulness is a symptom that plagues all of us at all stages of our life. As physicians, we need to discern which patient needs an MRI, or more importantly, in which cases can this condition be reversed. As the French philosopher Montaigne pointed out, you can be knowledgeable with another man’s knowledge, but you can’t be wise with another person’s wisdom. Surgical wisdom is just as hard to attain as the spiritual one.
In my opinion, any elderly patient who has recent onset of forgetfulness should have their brain imaged. While blood accumulation is not uncommon, on occasion, I have also found tumors in the frontal lobe—the area that aids in planning, execution, processing feelings, and memories. I’ve also picked up an extra accumulation of fluid in the ventricles, which, when drained, reverses these symptoms. More importantly, forgetfulness is commonly seen in those having deficiencies of Vitamin B12 and low thyroid levels and can be easily reversed by supplementing them. So, before we start prescribing pills for dementia, let’s try and take a look at what’s going on inside; also because there’s a high chance your patient won’t remember taking the pills!
“How do I keep my brain sharp?” a lot of people ask me. “Clean living and keep moving” is my standard response. There is really no rocket science here. Exercising, healthy eating, a bedtime routine, sound sleep, yoga, meditation, and expressing gratitude is what every single self-help book will tell you.
The other day, three lovely old ladies came to take the vaccine at my hospital. They were in their 80s and I had made arrangements for them to be taken care of, as one of them needed a wheelchair. I came down to visit them in the waiting area where they relaxed for the mandatory 30 minutes once they took the jab. “Hi!” I said, happy to see them dressed in nice floral skirts, their faces powdered in the characteristic way that elderly Parsi women step out in the afternoons. “Can you give me some medication for my memory, please?” the one in the center said. “I’m forgetting a lot these days.”
“And she fumbles with her words too,” her friend added.
“This COVID is driving us insane,” the first justified. “It’s so depressing. Plus, we live alone. What if we get it? There are no vibrators available anymore!”
There was a delightful silence. I know she meant ventilators, but I didn’t have the heart to correct her, I wanted to enjoy the moment. Also, I don’t judge.