Bharadwaj at 74 years was alert, active, enjoyed life as a whole and the company of his son, daughter, their spouses and their children. Born into an illustrious industrial house of Madras, he pursued his engineering studies abroad and came back to join, along with his 3 brothers, the industry founded by his father. In contrast to Jayaraman our other patient with dementia, here was Bharadwaj, with a huge extended family, all living close by, with him and his wife living with the son’s family, with a doting daughter and family next door. Socializing within this inner group, with true camaraderie and meeting over a meal on the multiple Indian festive occasions with exchange of gifts, and taking turns in singing south Indian classical music compositions solo or in groups was the traditional practice, a form of partial community living which could curb individuality, but did have its benefits for extended families that kept in close touch. There was support through thick and thin from extended family, close family ties among large extended families being common till 3-4 decades ago. The advantages of such mutual support is slowly being eroded as families scatter and few of the younger generation, who migrate to greener pastures in the quest of employment and upward mobility, are left behind.
Exploring the Condition
Bharadwaj’s loss of cognitive ability was subtle and demonstrated itself as changes in mood and behavior. His family noticed several changes in him over time; he became progressively withdrawn socially, spoke very little, stopped watching TV or reading the newspaper. In stages, fatigued, depressed and lacking motivation, he confined himself to bed, and with less physical activity, he became a near recluse in the midst of the over-reaching social interaction around him. More worryingly, for the family, the gregarious family man became paranoid and prone to spells of aggression, a change that was both frightening and distressing. No amount of coaxing and cajoling from his son, daughter and other close family members could shake his resolve to slowly fade away. It is in this mood that he was brought to TriMed-Neurokrish, stubborn as a mule and refusing to co-operate for the comprehensive assessment and showing resistance to undergo therapy.
Bharadwaj was not diabetic or hypertensive. His lab reports were unremarkable. He had followed the middle path in his lifestyle, well-disciplined, with no excesses, and no smoking or drinking. He was, however, addicted to south Indian classical music, and would venture into complex pre-composed music, and sing along with his daughter in a state of joy and sheer abandon as the melody flowed in an unfettered cascade. Where had that music gone?
It was the gentle persuasion of the daughter and daughter-in-law on the one hand, and the professional prowess of the TriMed-Neurokrish team on the other, that saw the thawing of Bharadwaj‘s adamant early phase, and he entered the phase of acceptance of the assessment and integrated therapy, though rather grudgingly to start with. A diagnosis of Dementia, stage 2 was made, knocking threateningly at the doors of stage 3 if not intensively managed. His behavioural manifestations were those of apathy, irritability and aggression on the Neuropsychiatric Inventory (NPI).
Our Healing Approach
Bharadwaj was already on Admenta (memantine) and Cognix (piracetam) along with a mood elevator prescribed by a Neurology Consultant, who had seen him in early 2015. We added a small dose of an antipsychotic, Olanzapine. With strengthening of the lower limbs and gait training, Bharadwaj became less dependent as he walked with minimal support, and his low back pain, and body pain, which he had brought upon himself with poor physical activity, was under control. Abhyanga (Ayurvedic whole-body warm, herbal oil massage), Shirodhara (Ayurvedic therapy that involves gentle pouring of liquids over the forehead) and Acupressure ran parallel, as part of the intensive therapy. Reflexology was also introduced. It was a slow and tedious process that shook off the negative apathetic behaviour and veered Bharadwaj toward a more positive behaviour.
Reflexology is an ancient traditional massage form, involving particular areas of feet, hands and ears which are believed to represent specific human internal organs and body systems. These areas have been mapped elaborately especially to guide foot reflexology. The skilled massage can achieve positive changes in the function of these organs and systems and is also effective in neck, upper back, lower back, painful disorders of the spine, and knee pain. In the book “Relieving Pain At Home” authored by William H. Fitzgerald (1917), an ENT specialist, he observes “Humanity is awakening to the fact that sickness, in a large percentage of cases, is an error of body and mind”, echoing the modern concept of body-mind link in many chronic medical conditions. Reflexology as a discipline shares the common belief of the ancient therapies, in that of opening of any block in the energy channels of the body.
Cognitive retraining is a therapeutic strategy that seeks to improve or restore a specific person’s skills in the areas of paying attention, remembering, organizing, reasoning and understanding, problem-solving, decision making, and higher level cognitive abilities. The primary aim of this therapy is to train the patient to overcome the cognitive difficulties that interfere with day to day activity, towards gaining independence in activity.
Retraining usually begins with simpler cognitive skills like attention, short term memory and information processing and then proceeds to more complex skills like problem solving, and executive function. Each identified lost skill is retrained using graded practice of activities. Cognitive retraining involves repetitive practice that focuses on the skills of interest. Repetition is essential for the newly retrained skills to become automatic. Cognitive retraining requires a quiet room without distractions and the patient must be able to relax to receive optimum benefit from the retraining.
Alex Bahar-Fuchs A, Clare L, Wood B Cognitive Training and Cognitive Rehabilitation for persons with mild to moderate dementia of the Alzheimer’s or vascular type: a review Alzheimers Res Ther. (2013) 5 (4): 35
Malhotra S,. Bhatia MS, Rajender G, Sharma V, Singh TB Current Update on Cognitive retraining in Neuropsychiatric disorders Review Article Delhi Psychiatry Journal (Oct. 2009) 12 ( 2 ): 213-218.
At the 6 month follow up, Bharadwaj is well overall, except for the occasional disturbances at night.
- Aricep (donepezil) 10mg – 1-0-0
- Admenta (memantine) 10mg – 0-0-2
- Cognix Plus (piracetam + gingko biloba) 1-0-1
- A to Z 1-0-0
- Supracal A (calcium + D3) 1-0-0
- Epitril 0.5 mg (clonazepam) was prescribed SOS at bedtime
He continues his therapies once a week. Bharadwaj walks with a little support within the house, is more independent in his self care, but needs help with soaping himself, and toweling after a bath. He socializes with immediate family members and language is more fluent and the content shows improvement. The lyrics of familiar songs are well recalled and musically expressed, as they go with the melody and the beat. Being able to sing puts him in a mood of elation. Perhaps most striking, he has islands of great clarity in thought and expression now. Recently, while watching a cricket match (another of his erstwhile passions) on the television, he regaled his family to their delight with comparisons, about the innings being played and another famous one from cricketing history. The family is pleased to see Bharadwaj enjoy some quality of life and never miss the once a week therapies.