avatarBertrand Liang, MD PhD

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Pitfall Memoir

Tony: Hearing What’s Said

Listening and hearing

By the authors, on Flickr.

Tony

Tony came into clinic with his wife, who was dominant with respect to her demeanor — talking nonstop to her husband, as I entered the room. She didn’t stop despite seeing me, and Tony actually arose to greet me as his wife continued speaking to her husband.

“Nice to meet you,” I noted to the patient after shaking his hand, and said the same to his wife, who continued to speak to her husband and just nodded her head at me, with the concluding clause, “…and you need to remember that.”

After sitting down, I asked the patient why he was in the Neurology clinic. His wife began speaking, and I asked her to stop, so that I could speak with the patient and get his perspective. After a strained silence of a couple of seconds, the patient began.

“I think I have dementia,” noted the patient, quietly. Looking up, I asked the patient why he thought that.

“Excuse me?” I repeated myself, louder this time.

“Well, I don’t remember things anymore. My wife here tells me that.”

His wife added, “And he has family that has dementia. His dad’s dad had dementia, and his mom’s brother.” I asked Tony if this was true, and he confirmed that it was. “How old were your family members when they were diagnosed?”

“Well, I think grandad was at least 80, and my uncle was probably around that age.”

“Any one else?” “Not that I know of,” said Tony, shaking his head.

(Mis)perceptions

I then explained that familial dementia was rare, and that at Tony’s age, in his early 60’s, if it was familial, it might follow the same pattern. But usually that familial dementia presented itself early, and it was the spontaneous type that presented late.

Tony’s wife spoke up. She’d looked up Alzheimer Dementia on the internet, and that Tony exhibited all the symptoms of the disease. He was forgetful, and often sullen. He didn’t speak as much as he used to, and when he did, only a few words. And sometimes he just didn’t answer he when she asked him a question, and just continued to read or watch tv or do whatever he was doing.

“His behavior is very much like the website I was reading,” she concluded, with finality. “We scheduled this appointment since his primary care doctor wouldn’t prescribe the Aricept that I wanted for him. She said we needed to see a neurologist first. That’s why I, I mean why we, are here.”

I listened, dutifully writing things down, considering how Dr. Google had made yet another diagnosis for me, and all I needed to do was to write the prescription.

Listening

I asked Tony some questions, regarding getting lost, or being found in an unfamiliar environment, or wandering — all of his answers were negative, noting that he knew his memory wasn’t what it was. I asked about his wife’s report, and whether he was ignoring her.

“Not intentionally,” he said, somewhat hesitatingly. “I just don’t hear her sometimes.” Looking up, I saw Tony’s spouse roll her eyes. “I just don’t, really.“

I asked the patient what he used to do for a living, and he had worked in a canning factory for about 20 years. They would regularly test hearing, and unfortunately one day, when his hearing was tested, his boss sent him out and had him go to the clinic at the company, then took him out of the plant. He was told he’d need either to retire or to take another job, which would be in the adjacent offices.

“I just took retirement,” said Tony. “Biggest mistake I made. But I didn’t want to learn how to be a clerk. I just wanted to be with my friends.”

Changes and discovery

“He was miserable,” noted his wife. “But he started to volunteer at the high school, but stopped after having problems understanding what was going on. That was a few months ago.”

I asked Tony what he perceived about that, and he just said he just didn’t recall being told things or hearing what needed to be done at the school’s shop. “I just decided I wasn’t all there anymore and quit.” There was a silence.

On examination, Tony actually did well on virtually everything except concentration abilities; he didn’t even try to spell or name or other things within the exam. However, his memory and constructional abilities were intact.

His exam did show something which I had suspected through the interview — that he did have a significant loss of hearing. This was both for higher frequency, as well as volume. And, he was depressed, probably a reactive depression, given the lack of pleasure of doing activities that he’d previously found pleasurable, and rather, would just sit around the house, staring blankly at the tv. Tony’s wife noted that she would try her hardest to get him to do things, to get him engaged, to motivate him. But to no avail.

…and hearing

“I’m not sure you have dementia,” I told Tony, and his wife after his examination.

“At least nothing classic as a dementia syndrome. I think you’re more likely depressed, and that you have another issue — you’re hearing is affecting your life dramatically. We need to address both of these.”

Tony’s wife began articulating her efforts once again, and I held up my hand. “I appreciate it but we need to rule out these causes before making any diagnosis. That’s something we always do.” Tony spoke up, asking what we needed to do next.

“Well, minimally, I’d like audiology to see you, and the ear, nose and throat (ENT) doctors, and as well, psychiatry in order to assess all of these issues. I’d also like to get some neuropsychometric testing, to evaluate your cognitive, or thinking, abilities, but only after you’ve seen everyone else first. Once you’ve seen all of them, we can get together again and go over all the results together. Tony nodded, and his wife, to my surprise, also just nodded.

A new day

Tony was seen by the hearing service, who fitted him with hearing aids, with the ENT doctors noted just presbyacusis, or being hard of hearing due to age. The psychiatry service did feel that he was depressed, and started him on an antidepressant.

After a few months, Tony and his wife came back to see me. He was a changed person. From being actively engaging with his wife, who was much less vocal, to seemingly brighter and more forthright, he greeted me heartily as I came into the exam room. I told him he looked better, and he noted he felt a lot better.

“He’s still forgetful,“ noted his wife, with a smile. “But it’s selective. Like when I want him to empty out the dryer. Or take out the trash. But other stuff he seems much more with it. And he doesn’t ignore me as much anymore.”

I asked Tony his thoughts. “It was the hearing, I think, doc — I just wasn’t hearing things. I didn’t think it was that bad, but the audiologist said it was — I was missing half the conversation most of the time. And I didn’t even know it.”

He’d started again volunteering at the high school and told the lead teacher about his hearing aids. They even used this as a subject on safety on hearing for kids going into the trades. In the end, I didn’t bother getting the neuropsychometric testing, since his examination was entirely normal. I still see Tony since he wanted to be followed in Neurology, but he’s clearly better now.

I was happy that I could appreciate what was going on with him and hear what he was telling me when we first got to know one another.

No need for Dr. Google’s Aricept, after all.

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