Rethinking Cognitive Decline in Older Adults: A Physician’s Perspective

Dr. Em Wong is a doctor of internal medicine and brain health coach with a background in women’s health and integrative medicine. An artist and author of iHeal Mag online, she is writing a book, “Vibrant to 100: Extend Your Brainspan and Shape How You Age.” Her goal is to be healthy of mind and body at her 100th birthday party — and she wants to invite you along on the journey.

Lily was 86 years old when she and her family were convinced that she was in the early stages of dementia. She would lose the thread of conversations and had to ask the same questions repeatedly. A minor stroke a year before had left her with leg weakness and she seemed to prefer to sit alone at home in her wheelchair most days. 

Lily’s children put her name on the 3-yearlong waitlist for government senior care homes in Hong Kong, where she lives, anticipating that full-time memory care would soon be needed. The social worker who came to assess her agreed that this plan made sense.

Lily’s daughter Melissa saw the plan for senior care placement as realistic, since she and her siblings worked full-time and couldn’t commit to senior care. But she felt sad when she saw how her mother became depressed and withdrawn whenever the topic came up. She decided that she would try to help her mom enjoy her remaining time at home, creating more happy memories together while they could. 

Small Changes, Quiet Resistance

Melissa had read that social connection and physical movement could delay the progression of mild cognitive decline (MCI), so she started taking her mom out on weekends with friends. Lily always complained and resisted ahead of time, but she  seemed to have a good time once she was out and about. 

Melissa even caught her mom laughing out loud once or twice – something that never happened at home any more. 

Melissa also encouraged Lily to stand for longer periods at home with her walker. She taught Lily’s caregiver to lead her in doing simple knee lift and leg extension exercises, to help build more strength in her legs. 

Melissa found a deal on family portraits and got Lily to come sit in the studio with her for a family photo, something their family had never done before. Lily seemed to enjoy looking at those newly framed photos of herself, along with older ones that had been on display for decades. 

Addressing What Wasn’t Being Said

One night while Melissa was staying overnight with Lily, she heard her mom get up to the toilet every half hour. The next morning, she got Lily to admit that she was getting up to pee even when she didn’t need to, because she was afraid of wetting the bed. 

Melissa tried to address Lily’s anxiety around bedwetting by normalizing the idea of sleeping with adult diapers and a mattress pad. She thought that her mom would be on board with getting a good night’s sleep, but Lily stubbornly stuck to her routine. It took endless cycles of trial-and-error over eight months for Melissa to eventually get Lily down to just two or three visits to the toilet at night.

When the government social worker came back again to assess Lily two years later, he was shocked to find Lily standing up to greet him and answering his questions clearly. The social worker decided that Lily wasn’t suitable for senior home placement after all, and enrolled her instead for an in-home physical therapy program designed for aging in place at home.   

 So what’s the story behind Lily’s remarkable turnaround? 

Lily’s MCI was probably due to sleep deprivation from her fear of bedwetting, an extremely common situation for elders. She felt embarrassed from the toileting accidents she had experienced, and didn’t want anyone to find out. Lily blamed herself for being weak and burdensome to her family. 

She was neither able to express her wish to remain living in her own home, nor her fears about incontinence. Instead she became anxious and depressed, which further compounded her cognitive difficulties. Lily’s situation is a typical default pathway to senior home placement. 

Rethinking Cognitive Decline

However, it’s not inevitable that elders will develop dementia, just as they won’t inevitably end up in wheelchairs. There’s a huge range of mental sharpness amongst elders, as there is with physical abilities. Forgetfulness can occur at any age, especially when illness and stress are at play, affecting the brain’s ability to function optimally. The problem is that when cognitive impairment happens in elders, there’s more of a tendency to accept that progression is unavoidable. 

Lily‘s story serves as a good reminder that figuring out what’s affecting brain function takes time, and a bit of trial and error. Lily dreaded losing her memory and appreciated Melissa’s efforts, but she felt that nothing could be done about it, so why bother? 

Melissa had to keep reminding herself that no matter how frustrated and helpless she felt, it was much worse for Lily who wasn’t able to problem solve for herself. She gently pushed past Lily’s reluctance to go out, treating it like an experiment. If Lily had seemed worse after an outing, she would have stopped. But neither of them could know until they tried. Like many elders, Lily was naturally resistant to doing anything outside of her comfort zone, but surprised herself when she had a good time. It took time for Lily to learn to trust in her daughter, but in the end Melissa’s persistence, sensitivity and tact paid off. 

The tragedy narrative of dementia tells of how memory issues inevitably lead to cognitive decline and loss. But that’s an overly simplistic view that doesn’t reflect the fact that cognitive impairment may stabilize, progress or even improve. We are best served by staying curious and proactive. No one can predict the future, but staying physically active and emotionally connected makes it more likely that we’ll be able to handle whatever comes our way.