An exotic behavior change occurred one day to someone my wife knew when still in college at UC-Santa Barbara. A friend had what was then known as Pick’s Disease, but no one knew it yet. Now called frontotemporal dementia, one of the brain deterioration’s early signs are personality changes. Her friend was a nurse so fastidious about cleanliness and eating clean, organic food that when she was seen eating cast-off scraps from garbage cans, my wife knew something wasn’t right. I read Travels with Lizbeth by Lars Eighner soon after it came out. The chapter about dumpster diving was anthologized in college readers. I tried out the practice myself for a while after reading it and was rewarded with lots of edible incentives; some decent or salvageable food gets tossed with the icky stuff. And yet her friend’s behavior still sounds ominous decades after hearing it retold.
I can think of a dozen reasons someone’s behavior can take a turn, many I’ve witnessed and tried to help families in hospice understand and treat. hospice related. The emergency nurse or physician might add another twenty reasons, but that’s too long for a blog post. Let’s start with some of the typical hospice diagnosis, starting with AAA, ascending aortic aneurysm.
In the ED these signs show that something isn’t right, especially if the patient has a feeling of impending doom along with a falling blood pressure, pointing to shock: Weak pulse, clammy skin, rapid heart rate and rapid, shallow breathing, chest pain and shooting pains in arms or legs, confusion and other signs of worsening consciousness because of the oxygen-poor blood bathing the brain. A leaking aneurysm could be the cause of internal bleeding. My sole AAA patient this week is weakening from weight loss and because of this could well be re-diagnosed with CVD, or cerebral vascular disease, but if one day I find her blood pressure tanks, after getting a panic call about mom fainting and sweating, I’ll know AAA was the right diagnosis and she’s bleeding out, soon to be dead. It’s wonderful that she’s eating but I’d prefer not to flatter, like Damocles tried to flatter Dionysius, but instead remind the family that she may die at any time. Still, I get swept along sometimes in their peppering me with dietary advice. Everyone likes happy talk about eating.
Alcohol is the quickest and most common means of purposely changing a mental status, the surest contributing means to an overdosing death, and by its prolonged-heavy becomes a co-morbidity. When our filtering (liver) and cardiac systems become so engorged with fatty deposits from alcohol abuse, they fail, and we’re soon introduced to that “6 months or less” expiration date club. The alcohol factor contributes to a profound percentage or degree of vehicle crashes, murders, intimate partner violence, rape, addiction, and social humiliation, not to mention the billions or trillions of GNP loss due to illness, work loss and plain old-fashion death. Not that I care about the markers of a country’s imagined well-being, which isn’t being well enough toward the 70-90% of us.
Allergies and drug reactions at their life-threatening level might be put under the Anaphylaxis heading. From mild to severe, the changes are dramatic, but not essentially thought of as behavioral or personality changes unless one is mistakenly inspired to cast shade upon someone with a closing airway and a look of saucer-eyed panic. Milder skin reactions could be shingles if the bumpy rash is on only one side of the body.
Let’s take Alzheimer’s Disease for $200, Alex (speaking of a change of condition). There are basically five dementias, of which Alzheimer’s is the best known from being notorious for its reputation of insidiously stealing away personality and frustrating long-standing relationships. The other dementias are Lewy Body, marked by Parkinson-like tremors and stiffness, insomnia and hallucinations; Vascular dementia that looks similar to Alzheimer’s but results from neural cell death as a result from blood-blocking strokes both catastrophic and barely noticeable; Frontotemporal degeneration of brain tissue that shows up earlier in life and in this essay’s lead-out paragraph; Mixed — usually a combo-cause of post-stroke and Alzheimer’s Dementias.
By and large Alzheimer’s Dementia is a slow, protracted course of mental, functional and personality decline with a dreary, day to day sameness one can be excused for expecting to continue until one day the big change is marked by trouble with swallowing, marked by coughing, perhaps an aspiration, leading to pneumonia and death. But once a functional decline occurs in Alzheimer’s dementia, you don’t get back that former capacity. It’s a Progressive disease, inevitably getting worse. Perhaps now it’s merely coughing; then you adjust the food and drink consistency, making the food easier to swallow, like McDonald’s hamburgers, and the drink thickened with an added starchy powder. But soon there’s no more chewing, then no more swallowing. If only global warming ratcheted up the heat as suddenly (are you listening, Texas?), with weather crises as noticeable and consistently worse, then we might have the political will to address climate’s coming disaster and have us a future less full of catastrophe for those now under 50.
Bipolar disease. I’m not an authority on any one psychiatric illness despite working in-patient psych hospitals for about ten years and reading millions of words of original theoretical source material, writing an unfinished psych hospital novel, and majoring in psych, but I can say with confidence that bipolar — formerly “manic-depression” — or a sort of cycling mood disorder between creative flights of ideas and outright depression, is one of behavioral change. Bank robber George “Baby Face” Nelson in “O Brother Where Art Thou” is a comic exaggeration of one with this sort of disorder. Ignore any representations you’re presented in the popular arts, since the behavior shifts are more subtle than can be shown within film media in a scene or two. The memoirs on bipolar are legion and from many who are famous, since those so afflicted have perceptive minds that are lighting quick while in their upswings, and energies to burn for learning, reading, and writing about things they know something about, like their mercurial lives.
Brain tumors. “No one deserves not to have dexamethasone” is a saying in my hospice squad that fits one of my current patients, who babbles nonsense one minute then the next minute makes his family sit up and respect his ability to direct his own care. Brain tumors are especially noticeable in their progression and being where they are to compress cerebral tissue it’s not surprising that behavior changes come along. Pain and insistence on going to the hospital is soon followed by “I’m not going anywhere” despite 10/10 pain. Methadone every eight hours is found to have not been taken the past two days and so needs being replaced by fentanyl transdermal patches after stacking several 4mg doses of hydromorphone to play catch-up. Don’t try this unsupervised. Therapies vary.
Delirium, dementia, and depression: All three exhibit changes in memory, thinking, language, judgment, and behaviors. But Delirium is the sudden change, complicating its diagnosis because so often it’s overlaid onto dementia and shows up because of an unobvious infection (usually a UTI) or because of an un-reportable pain, typically constipation. The onset of delirium is sudden-acute and relieved with stimulus relief. If a depressed person shortly becomes jovial and sunny, whose disposion used to be one of a long and crushing weariness, this is ominous and that person needs to be watched extra carefully for suicide, since the sudden personality change-relief often coincides with having turned the mental corner about — and formulated a definite plan for — self-release from their painful bondage.
Injuries to head/repetitive micro-concussion: dizziness, headaches, personality changes, esp. after accumulation of a certain percentage of tau tangles often seen on postmortem microscope autopsy slides of Alzheimer’s disease or repetitive head injuries from playing American football. Happy Superbowl, fans, but many National Football League players past and present die in their 40s and 50s from suicide or otherwise suffer depression and incapacitating headaches because of the accumulation of the thousands of lifetime scrimmages that involve butting their helmets.
Post-diagnostic mood changes or those physiologic struggles after surgery, from the trauma of the operation or the anesthesia. Anyone who’s experienced an MI or been diagnosed with cancer, as seen in Arthur Frank’s At the Will of the Body (1991) — a practicing philosopher, he had both, in short succession — is not much of a thinking or feeling person if they don’t then have themselves a session or two of existential struggle, with sensing their limited time left, with finally arriving to a deeper knowing of their mortality. Give these family and friends your loving acceptance of their grief as they struggle to understand how they may need to face their death, especially if they are young mothers. I’ve seen the Lincoln Park rich hire death doulas to assist in the physical, emotional, psychological, and even spiritual support that comes from an unexpected terminal diagnosis.
How’s the blood glucose levels? Any acute consciousness status change while in hospital or a nursing home will soon get your finger poked and glucose checked. Too low is dangerous, marked by incoordination or other sloppy behavior and thinking. The mystery of undiagnosed diabetics in the world is solved with severe enough glucose levels and diabetic ketoacidosis, the signs of which are extreme thirst and abdominal cramps or nausea, severe enough to get folks into a hospital where they can get diagnosed, get some insulin and some follow-up testing and glucose management teaching.
I’ll pass up Lyme’s disease irritability (vectors of this tick-transmitting chronic disease is the field mouse, which are growing in number to infect humans because of our house-building encroachment on wild nature, causing die-off of the mice’s predators) Parkinson’s Disease and Menopause, since these are too widely known. But beware the next epidemics and next pandemics, which are zoonotic transmission of viruses because we can’t leave enough nature for bats and other wild creatures. This trend is not nearly so well known outside of the experts on infectious diseases. Cf. https://www.youtube.com/watch?v=_v-U3K1sw9U
Strokes. When can we suspect that someone is having a cerebral blood blockage? Think FAST, and compare Face/Arms/Speech, along with knowing that if the stroke victim gets an antithrombotic medication within an hour’s Time, their chances of recovery average out to pretty darn good.
- Face. Tell the person to smile. Watch to see if one side of their face droops.
- Arms. Have the person raise both their arms. Watch to see if one is weak or sags.
- Speech. Ask the person to say a simple phrase. Listen for slurred or strange-sounding words.
- Time. Every minute counts. Call 911 right away.
- confusion, paralysis, swallowing difficulty, metallic taste…it all adds up to el Strokerino. Don’t try to drive them to the hospital but call 911 because the stroke medical protocols are well known and get started right away then the paramedics show up.
American football is the blood sport I love to hate upon for many reasons I won’t write about now, but instead wish those so addicted to its violence and human exploitation a very Happy Super Bowl day!
Hospice Nursing 1 Day at a Time 