What is an appropriate yardstick for measuring brain wellness? It’s not like measuring physical wellness. We can run the same distance each January 1st to see how we measure up but for brain wellness a similar test is not realistic. Solving the same puzzle or taking the same quiz doesn’t work because our memory might remember the answers from year to year – at least some of them. Rather, we rely on subjective measures like how we feel or how something seems. “I never had trouble remembering my daughter’s phone number before” or “I used to be able to balance my checkbook without mistakes” might be common yardsticks. And even if there were standardized tests for measuring brain wellness my sense is that few adults would take them regularly or willingly.
Many of us are familiar with the “mini-mental” used by neurologists and other practitioners. But given its simplistic format the answers quickly become embedded in our brains – world spelled backwards: D-R-L-O-W, etc. So the value of this test diminishes over time – some would even suggest it starts with little value! So how do we measure if our brains are not working as well as they used to? How can we measure both the amount and rate of decline? And what value is this information if we could measure it accurately?
When it comes to cognitive wellness there is black, there is white, and there is gray. Someone of sound mind or someone with serious dementia stands out but the gray portion of the spectrum is quite wide. And unlike heart rates or blood pressure levels there is no defined “normal” range even if there were a test we all agreed on. Instead we are left with doctors and families measuring us subjectively. Do we seem more vague than usual? Are we more forgetful or confused than last year? Do we not get a joke without an explanation? Do we miss appointments with friends because we forgot what day it was? Do we show less interest in intellectual activities like lectures or book group? All these things are indicators of mental decline but often can be easily explained away.
Then there are the secondary symptoms. Is our mood different? Frustration caused by getting lost or not being able to follow a lecture looks the same as frustration over not solving the Sunday crossword puzzle because it is genuinely difficult. Lack of interest in bridge looks the same whether it is due to being tired that day or from fear of looking foolish when we forget the trump suit. Someone who orders a pizza for breakfast might be acting a little more eccentric than usual or might not know what time of day it is. These secondary symptoms of mental decline are easy to cover up especially since the gray area is so gray and most people are afraid to confront someone they feel is declining. Even someone with dementia can retell a story from their childhood and even a sharp person can forget what day it is. And we are all adept at covering a mistake, pointing to reasons for it, or downplaying its significance.
The reason brain wellness is such a touchy subject is because it can be quite subjective and also because it basically defines who we are. Many will admit to losing strength as they age but few will admit to being less sharp mentally. There is a social stigma attached to it. I can say I am having more trouble doing the crosswords or solving a Sudoku than i used to have but you better not point it out! It is generally agreed that there are some people who are far more intelligent than others. But if asked where we are on the spectrum of genius-to-fool my guess is that an overwhelming majority would rate themselves above average – and it doesn’t take a genius to figure out that the math doesn’t work that way!
The bottom line is that there is no clear measure of mental competence. Thus, we are left with the mess of deciding when someone should stop driving or when a power of attorney or health care proxy should be enforced. Compounding the problem is that, as with almost anything, the decline is not usually steady or readily predictable. Some people have good days or bad days and even some Alzheimer’s sufferers have lucid moments. Perhaps there is some predictability related to time of day or the seasons or how tired someone is but overall the rate of decline is a wildcard.
If this were not difficult enough we need to remember that some people can make up for one deficiency if they have other strengths. Consider cavemen. A smart caveman out hunting for a day may be able to locate twice as many deer than a caveman of average intelligence but both will bring home the same amount of venison if the average one is twice as good with his spear. And the caveman with average intelligence and average aim will still match his contemporaries if he can endure a two-day hunting trip. In prehistoric times it is unlikely that the measure of a man’s self worth rested on his intelligence, more likely it was based on his ability to bring home venison. But in today’s society our minds are a more critical part of who we are especially as we get older and our physical abilities diminish.
We are not as comfortable acknowledging our intellectual deficiencies and a decline in mental competence is downright embarrassing. And then there is the fact that often the elder is being told by their own child, to whom they were once omniscient, that they are not as smart as they used to be. It is no wonder that telling a parent that they are no longer capable of making their own decisions or that they can no longer be behind the wheel of a car is one of the toughest chores in the world.
So what can be done about this? Sorry, this is a discussion, not an instruction manual. I don’t have an answer. For some things a competency test is the answer but not for everything. I will obviously revisit this topic in future blog entries, but for now this is simply food for thought. How fitting on the eve of Thanksgiving! Have a good Holiday everyone! Oh, and the error in D-L-R-O-W was intentional!