Dying in Dementialand

I pulled up at a nursing home in an impoverished part of Kansas City. It was 2006–before GPS was commonplace. I had printed out Mapquest directions to find this place. It didn’t help that it was raining, almost 11 pm, and that the nursing home was tucked behind an authentic hole-in-the-wall Mexican restaurant and one of those Payday Loans joints, but I found it.

I was part of a new volunteer program that a hospice in the area had started. If a nursing home resident was “actively dying” (a hospice term used to describe what is typically the final 24-72 hours of life) and didn’t have anyone to be with them, we were called. I had taken the 11 pm to 3 am shift with a women dying of Alzheimer’s.

Although often people don’t understand that Alzheimer’s can be a cause of death, it is a terminal diagnosis. Many people pass away from other causes before Alzheimer’s kills them, but at some point Alzheimer’s degrades the brain to a point where it can no longer provide support for functions like breathing, swallowing, and fighting infection. That was the point my hospice patient had reached. Her body systems were shutting down due to Alzheimer’s.

Her name was Opal. Actually, that wasn’t her real name. I’d like to say I changed her name to protect her privacy, but the fact is that I don’t remember what her name was. And I feel like a horrible person for not remembering her name. After all, I was with her on her final journey, and that’s pretty significant.

Opal was an African-American woman in her 70’s who didn’t live in a great nursing home. It was dirty, and it smelled awful. If a horror movie were set in a nursing home, it’d be this place.

And just when I thought things couldn’t get more eerie, I saw a large rat. Upon closer inspection, I realize it wasn’t a rat. In fact, it was a small-ish shaved cat. The nursing home liked the idea of having a cat but knew some people might have allergies…. It was perhaps the creepiest-looking cat I’d ever seen. I termed it “Rat-cat.”

I found out that Opal had a daughter living across the country who had visited several weeks ago. Her daughter had been notified that Opal was passing away, but she couldn’t make it back. According to the hospice volunteer coordinator, the daughter had said she saw no point in coming back because Opal wouldn’t know she was there anyway.

Opal hadn’t recognized anyone for several years, and she’d been unable to speak for quite some time. There were some greeting cards taped to the wall behind her bed. I felt guilty about snooping, but I read them anyway. Most were religious cards that appeared to be from cousins, nieces, and nephews. One note mentioned that the sender had included a gift card to Walmart. I’m pretty certain that Opal hadn’t been up for shopping for quite a while. Except for her daughter’s recent trip, Opal hadn’t had any visitors in months.

For tonight, Opal had me. She seemed comfortable but not at all alert. Her eyes were slightly open but she didn’t seem to be able to see anything. Her breathing was labored and they had her on oxygen.

My job was to make sure she seemed peaceful and to alert the staff if I felt she was in pain or distress. More than anything, I was there to make sure she didn’t die alone.

A young nursing assistant stopped in frequently to check on her. My original prejudices about the nursing home were challenged by her cheerful and efficient demeanor. She was amazingly gentle in repositioning Opal and kind in talking to her. The nursing assistant told me to come find her if “things start changing.” I knew what she meant.

I spent most of my time sitting in a chair by Opal’s bed. I didn’t talk a lot. The TV was on when I came into the room, so I left it on and stared at it mindlessly for a few minutes at a time. There were a couple of books of devotionals on Opal’s nightstand, and I thumbed through them without really reading. At one point, I did start reading something from the devotional books aloud, but it didn’t feel right so I stopped.

The nursing assistant mentioned that Rat-cat tended  to frequent the rooms of residents who are dying, and sure enough it stopped by a few times. Mostly it just sat in the doorway and stared at me. I stared back.

I left that night not knowing if Opal even knew I had been with her. I slept a few hours and went to work the next day. I was signed up to go back the next night but had a feeling she would pass away before I got there. However, Opal was still around at 11 pm the next evening.

If you know me, you know I don’t do well on limited sleep. As I headed back to the nursing home, I was exhausted. I stopped to get a soda at a 7-11. Somehow I was distracted by the Slurpee machine and decided to mix the cherry and Coke Slurpee–something I did frequently as a kid but probably hadn’t done in ten years. And it was so good.

I brought it with me into the nursing home and stopped to see the nursing assistant at the desk. When I got to Opal’s room, I realized I had left my Slurpee at the nurses’ station. I had just greeted her by putting a hand on her shoulder and telling her who I was when I thought I’d retrieve my Slurpee, but when I took my hand off her shoulder, she made a noise.

It wasn’t something that indicated she was in pain, but it wasn’t a “good” noise. I put my hand back on my shoulder and she was quiet. I took my hand off her shoulder again, and she made the same noise–and continued to make it–until I put my hand back on her shoulder. She obviously didn’t want me to take my hand off her shoulder. She didn’t want me to leave. And, yet, I really wanted that Slurpee.

I said, “I am just going to the nurses’ station to get my Slurpee and will be right back. I will even run.” Despite her making the same noise, I took off to the nurses’ station in a full sprint. I grabbed my cup and sprinted back. I put my hand back on Opal’s shoulder, and she was quiet again. I sat with my hand on her shoulder while drinking my Slurpee for quite some time.

Rat-cat came and sat in the doorway. I wasn’t quite as creeped out by it the second night. In fact, I had gotten over the initial shock of his appearance and realize he was–in his own way–almost cute.

I wish I could tell you that Opal rallied, or at least that she opened her eyes and shared some departing wisdom with me. I wish I could share with you that I learned a life-changing lesson that would make me an infinitely better person from my time with Opal. I’d love to say her daughter called to thank me for sitting with her mom or maybe that another family member stopped in to say goodbye. None of that is true.

She passed away that night about 45 minutes after I left. Another hospice volunteer was with her. Unfortunately, the hospice failed to let me know, so I went back the following night. Rat-cat was there, but Opal’s bed was empty.

As I sit here nearly ten years later, I would give anything to remember Opal’s real name.

Til Death Do Us Part in Dementialand

She had taken off her wedding ring long ago because it was too painful to look down at her hand, see the ring, and remember that she had a husband who didn’t know who she was. But when she said she loved him as much as ever, I believed her.

This is not the post you expect it to be. If you’re looking for a heartwarming tale, you might want to check out “Chicken Soup for the Soul: Living with Alzheimer’s and Other Forms of Dementia.” (Yes, it really does exist, and it’s not a bad book if you’re into that type of thing.) But I’m not sure you’re gonna get warm fuzzies from my post today. In fact, I have no idea how you’re going to feel after you read this post.

In my visits to a nursing home, I met a bubbly nursing home visitor in her 50’s who I will call Jean. Although I tell this story with her permission, I have changed her name. Jean’s husband, who I’ll call Gary, was also in his 50’s, but his appearance would have lead me to guess he was in his 80’s. Gary, who had younger-onset Alzheimer’s, had lived at the nursing home several years. He was in end-stage Alzheimer’s and seemed somewhat stalled there.

He spent most of his time in bed. He had to be turned every few hours to avoid pressure sores. When the staff got him up in a wheelchair, he slumped over to one side–usually unable to keep his eyes open. He fought a constant battle against pneumonia (common among people in end-stage Alzheimer’s due to compromised immunity) and was on a thickened liquid diet to avoid aspiration. He had not spoken for over a year. Jean told me he stopped recognizing her long before that.

Jean worked full-time and stopped by every evening. Sometimes she sat with him and watched Wheel of Fortune while holding his hand. Once in a while, I saw her doing crossword puzzles. She enjoyed talking to other residents and their families. She was bright, caring, and always laughing.

If you’ve spent any time in nursing homes, you know that they can be gossip mills. I found out through the nursing home gossip mill that Jean had boyfriend. Not that she was hiding it. It had just never come up when I made small talk with her.

As I got to know her a little better, she’d mention her weekend plans or what she did the previous evening, casually dropping the name of her boyfriend. I didn’t ask too many questions. I’m sure she had enough judgement in her life, and I didn’t want her to misinterpret my curiosity as disdain. Frankly, it was none of my business.

But I learned more as time went on. Gary was diagnosed with Alzheimer’s in his mid-40’s. His mom had younger-onset Alzheimer’s as well, so they weren’t shocked, and they had an idea of the path ahead. They went on a few trips right after the diagnosis. Jean knew these trips would be bittersweet, but they ended up being more bitter than sweet.

Unlike many people who tell their loved ones to never put them in a nursing home, Gary told Jean that he didn’t want her to care for him at home as the disease progressed. He made the choice to put his mother in a nursing home although she repeatedly requested that he never do so. He lived with that guilt, and he didn’t want to Jean to have to do so.

When the time came, she placed him in a nursing home. She visited every evening. A few years later she met someone. She continued to visit Gary every evening. She told me she loved Gary as much as ever, but she no longer viewed him as her husband.

She had taken off her wedding ring long ago because it was too painful to look down at her hand, see the ring, and remember that she had a husband who didn’t know who she was. But when she said she loved him as much as ever, I believed her.

I can’t say Jean’s situation is the norm when a spouse has dementia, but I also can’t say it is rare. In fact, on the very same nursing home hallway where Gary lived, there were two other wives in similar situations. I am not speaking of wives who had abandoned their husbands at a nursing home. I’m talking about wives who visited at least once a day, were active participants in their husbands’ care, and had boyfriends.

It’s common enough that the Wall Street Journal wrote a story about it several years ago:

http://www.wsj.com/articles/SB10001424052748704317704574503631569278424

Even religious authorities are split on whether this is okay or not. I’ve kicked it around quite a bit, and all I can say for sure is this:

If I had dementia, needed 24/7 care, and no longer recognized my spouse, would I be okay with my husband dating someone else? The answer (for me) is absolutely yes. And I would not want him to feel guilty about it for one second. Of course, I haven’t been diagnosed with dementia. Could my thoughts on this change if I were diagnosed tomorrow and saw dementia a real rather than hypothetical part of my future? Of course.

I know that Jean was with Gary when he passed away. Til death do us part. Or something like that.

 

How I Got to Dementialand

I grew up in a nursing home.

My mom was a nursing home activity director, and I spent my time after school and on the weekends in the halls of Bethesda Care Center. I helped with Bingo, pushed people in their wheelchairs to the chapel for church, modeled my back-to-school clothes for a fashion show, and did dance routines for the residents. In some ways, being at the nursing home made me feel like a rock star. I got a lot of attention from the residents. They thought I was the cutest, funniest, and smartest kid they’d ever seen outside of their own grandkids. I relished every bit of positive feedback.

Of course, there were days when we’d pull up at the nursing home and find a gurney on its way out of the facility. A couple of somber men in suits were pushing out a body covered by a white sheet. I’m unsure if this is a fair representation or just my perception, but I would guess that 80% of the time we arrived at the nursing home to find someone had passed away it was storming outside. If we arrived to find a death had occurred, my mom would stop to quietly ask another employee who had passed away. Then she’d let me know. I don’t remember crying, even if it was a resident I really liked, perhaps because it was such an “ordinary” occurrence.

When you walked into the nursing home, there was a large board with each resident’s name and room number. Of course, it changed frequently with admissions, discharges, and deaths, but I took a lot a pride in being able to remember who was in each room even when I was 7 or 8 years old. If a visitor stopped me in the hall to ask if I knew what room Myrtle Smith was in and I didn’t know, I would be really disappointed in myself and study the board a little harder.

I spent time with people who had dementia. I didn’t know the term dementia when I was in elementary school. Now I know that dementia is not a normal part of aging, but at the time I didn’t realize that. I guess I just thought that some people got a little crazier or didn’t make much sense as they got older.

I knew that certain people at the nursing home didn’t realize they were at a nursing home. Some seemed to think they were at a school or a place of business. One woman thought it was an airport and she was trying to find her gate. They often thought I was someone else–many times they thought I was their daughter or granddaughter, but that was okay because it usually meant they were extra nice to me and wanted to spend time with me. I didn’t care if they called me by a different name. I never corrected them. In fact, sometimes I thought people had special nicknames for me. Looking back, those nicknames were probably the names of family and friends with whom they had me confused.

Their dementia was a perfect fit for where I was at developmentally. It allowed them to “play” with me in a way similar to how kids play with other kids. We pretended we were somewhere else–a different time, a different place. It was only years later that I realized I was pretending…I was using my imagination. They were NOT pretending. They were acting on their “reality,” and imagination had nothing to do with it. But it worked.

And it makes sense why it worked. If two kids play together and one pretends that they are cooks in a restaurant, the other kid doesn’t point out that they aren’t really in a restaurant. They jump in and play a role in the restaurant scenario. And that’s how it was when I spent time with residents who had dementia.

As for the woman who couldn’t find her gate at the airport…I noticed employees would tell her that she wasn’t in an airport at all. They’d insist she was in a nursing home, and she’d get mad. I never told her she was in a nursing home. I didn’t correct her because to me it was just all part of the game. And I found the game to be a lot of fun. We’d wander around until I showed her where her gate was. When we found it, she was so excited and grateful. And I felt like I’d won the game.

I had favorite residents, of course. A never-married woman who lived to be over 100 and could play the piano even though she couldn’t see a thing. A lady who had a tracheostomy but had crocheted colorful necklaces with patches to cover the hole in her neck. An old farmer never seen without his green John Deere hat. A woman who had a poster of a beautiful gymnast over her sterile nursing home bed. I found out that the gymnast was her 16-year-old granddaughter who had been killed by a drunk driver. I was fascinated by the poster. But these were my friends. They were always excited to see me and never failed to make me feel good about myself. It was more than I could say about the kids at school.

Many of my nursing home friends had colostomy bags and catheters. I knew quite a few wore adult diapers. Several were on oxygen. You might think that some of these things would be gross or scary to a kid, but they weren’t. I was exposed to them so early in life that it didn’t occur to me that I should be frightened or unnerved. And, so many people had them that they didn’t even register to me. If I noticed colostomy or catheter bags, it was often just to appreciate the bright covers that were knitted for them. I don’t think I knew the words colostomy and catheter, but I’d say something like “Ohhhh….I love your pouch, Elsie!”

Every kids grows up in a different environment. The nursing home was a big part of my environment. When people ask me why I became a gerontologist, I always start by telling them I was a “nursing home brat.” But I never intended to be a gerontologist and it was never part of my master plan. (For the record, I don’t believe in master plans, at least master plans that you make regarding your career when you are 18 years old.)

But there’s something about the field of aging that drew me in. I’ve told my college students that a great strategy for being successful in your career is to find something that other people find repulsive–but you find interesting–and throw yourself into it completely. I hate that many people find aging repulsive, but it’s undeniable. I would love to make a short video of the range of disgusted and confused faces I get when I explain that I actually ENJOY working with older people (especially those with dementia) and am FASCINATED by the process of how we age.

So here I am…a nursing home brat all grown up. I have a PhD in Human Development and Family Studies from Iowa State University. I’m a faculty member at university, where I get to oversee the Family Services and Gerontology program. I do research on psychosocial aspects and family knowledge of Alzheimer’s and related dementias, as well as how students choose careers in aging-related fields. I teach courses like Psych of Aging; Families and Aging; and Families, Alzheimer’s, & Related Dementia. I am fortunate to do public speaking on topics like dementia and caregiving, and I also do a program called Memory Trunks that allows me to visit with people who have Alzheimer’s and related dementias in settings like adult day services, nursing homes, assisted livings, and memory care units.

But here’s the thing…when I walk into a nursing home to work with people who have dementia, none of my credentials matter. The residents could not care less about my doctoral degree. It’s just like when I was a kid hanging out at the nursing home after school. All people with dementia want is for me to step into their world, listen to them, and help them find their gate. My goal is to let go of every bit of “adult” I have in me and relate to individuals with dementia in the same way I did when I was six years old.