Episode 42: Navigating Dementia in Your Holidays with Dr. Josepha Cheong

Dr. Josepha Cheong, M.D. chose a medical career to follow in her father’s footsteps. On her journey to become a surgeon, a fateful rotation during her clinicals directed her path towards psychiatry. Dr. Cheong’s work has focused on geriatric psychiatry in the hopes of further understanding dementia and other cognitive diseases.  

This episode of Menninger Clinic’s Mind Dive Podcast features Dr. Cheong, accomplished physician and psychiatrist joining hosts Dr. Kerry Horrell and Dr. Bob Boland for an extended look at dementia and how caregivers and family members of those with the disease can navigate the hectic holiday season.  

Dr. Josepha Cheong is a professor at the University of Florida College of Medicine, instructing in the Departments of Psychiatry and Neurology. She is board-certified in general and geriatric psychiatry and currently serves as a physician with the Malcom Randall VA Medical Center, the Geriatric Research, Education and Clinical Care Center (GRECC) and as a geriatric psychiatry consultant for the National Expert Consultations and Specialized Services-Mental Health (NEXCSS-MH). In addition, she serves as a director at both the American Board of Psychiatry and Neurology (ABPN) and the Accreditation Council for Graduate Medical Education.  

One of the most frequently asked questions in Dr. Cheong’s experience is how family members can identify when memory loss has become something more. “Dementia is a very general term that refers to memory impairment and then impairment of another brain function,” said Dr. Cheong. The doctor also stresses that dementia is never just an illness of the patient, but one of the family and the support structure, since the burden of care falls on everyone in the patient’s life.  

With holiday stress approaching, especially for families of dementia patients who need to travel, Dr. Cheong emphasizes the importance of balancing flexibility and routine for caregivers. “Did you raise kids? Do you remember what it’s like traveling with 3- to 7-year-old? That’s how you want to play it,” she said. 

Follow The Menninger Clinic on Twitter, Facebook, Instagram and LinkedIn to never miss an episode of Mind Dive. To submit a topic for discussion, email podcast@menninger.edu.

Visit www.menningerclinic.org to learn more about The Menninger Clinic’s research and leadership role in mental health.  

Follow The Menninger Clinic on Twitter, Facebook, Instagram and LinkedIn to stay up to date on new Mind Dive episodes. To submit a topic for discussion, email podcast@menninger.edu. If you are a new or regular listener, please leave us a review on your favorite listening platform!

Visit The Menninger Clinic website to learn more about The Menninger Clinic’s research and leadership role in mental health.

Transcript

Dr. Bob Boland: 0:02

Welcome to the mind dive podcast brought to you by the Menninger Clinic, a national leader in mental health care where your host, Dr. Bob Boland,

Dr. Kerry Horrell: 0:11

and Dr. Kerry her L. twice monthly, we dive into mental health topics that fascinate us as clinical professionals, and we explore those unexpected dilemmas that arise while treating patients. Join us for all of this, plus the latest research and perspectives from the minds of distinguished colleagues near and far. Let's dive in. Before we hop into our episode today, we do have a special announcement where we're hoping to elicit some questions from our from our audience base.

Dr. Bob Boland: 0:52

So we did this last year and it seemed to go pretty well. Yeah. But we mainly got questions from locals. So we kind of wanted to open up to everyone. So

Dr. Kerry Horrell: 1:00

if you have a question that you'd like us to answer, or more likely, just reflect on in an upcoming mailbag episode, please send us questions or ideas to podcast@menninger.edu Odd

Dr. Bob Boland: 1:14

cast and menninger.edu. Yeah. This is kind of by popular demand, right?

Dr. Kerry Horrell: 1:21

Yeah. Yeah, exactly. We're back by popular demand. Exactly.

Dr. Bob Boland: 1:25

Just us. Waxing like intelligently on impossible questions, people.

Dr. Kerry Horrell: 1:31

So hopefully you send us some questions and now on to our episode.

Dr. Bob Boland: 1:39

Today, we're really excited. We have Dr. Joseph Chong, someone we've known for quite a while at least I have and he's Carrie, you feel like you have right? I absolutely

Dr. Kerry Horrell: 1:48

just been chatting for the last 15 minutes. I feel like each other lifetime.

Dr. Bob Boland: 1:51

There you go. So she's a professor at the University of Florida College of Medicine Department of Psychiatry and Neurology. She's a board certified in general and geriatric psychiatry. She currently serves as a physician with the Malcom Randall VA Medical Center, geriatric research, education and clinical care center. That's one bill, how do they fit that name on there? They just got a rack. Right. And as a geriatric psychiatry consultant at the VA, national expert consult consultations and specialized services of mental health. So she works for the VA basically, as an expert their own me. They do. In addition, she's currently a director of the American Board of Psychiatry, neurology, the abpn and a director of the Accreditation Council for Graduate Medical Education. So she's responsible for really all medical education in the United States is pretty much fair to say, well, not me personally. Yes, pretty much and she's presented nationally on Geriatric Psychiatry, medical education, professional development and leadership. So welcome. Welcome. Dr. John,

Dr. Josepha Cheong: 2:54

thank you so much.

Dr. Kerry Horrell: 2:57

I was it's a privilege for us to talk with you. I'm so excited to have you. Yes, it is.

Dr. Josepha Cheong: 3:01

Thank you. Thank you so much.

Dr. Bob Boland: 3:03

So so many things that we can talk about, since you're an expert, so many things, but we're gonna be talking about your expertise in geriatric psychiatry. So first of all, you know, tell us about your career and like just how you got interested in studying dementia and geriatric psychiatry in general?

Dr. Josepha Cheong: 3:17

Well, I always knew I wanted to work with older adults because of hanging out with my grandmother for most of the time until I was in college. And she used to tell me, because she lived overseas, she says, she always used to tell me if you become a cardiologist, I'll move here, meaning to the US. And so I was like, Okay, I'm gonna work with older adults, and be a doctor. But I mean, it was kind of preordained. I grew up in a family, a Chinese family, my dad's a general surgeon, and I wanted to be a doctor because of him. Here's my family's just full of doctors. We've got four I've got three other siblings plus an in law, and then there's three in the next generation coming through plus one additional and pre med right now. So if we're, if my dad was a shoemaker, my guess is that we'd be making shoes and I would be making the purple ones. So it'd be the best shoes ever. I was tracking towards surgery or anesthesia, because I love procedures. And then as a third year, medical student on psychiatry, I saw literally still the most amazing thing I've ever seen in medicine, had a 70 year old patient who was psychotically depressed, kept saying that he was dead already that he had snakes inside his body. And that's why he wasn't going to eat or get up or anything, had just given up and stopped eating lost a bunch of weight, my attending at the time, who I adored and still do decided at round one time after the interview goes well, we have to do AECT as a third year medical student, we're talking late 80s I'm thinking do they even do that anymore? And I just thought it was the craziest thing and I just saw psychiatry is kind of an easy break and a very difficult third year of clinicals. And in a space of a week and a half, after only four treatments, it was amazing to see literally somebody almost dead, come back completely to life. And I don't understand it, but that's what I'm going to do. And that literally was it. Wow. And yeah, I mean, it was just it was just that fantastic. And I still think it is. And it's amazing to be able to do that, and really kind of got into that. And I started continuing as an elective. Doing a Wednesday clinic with Ken Heilmann, who are neurologist behavioral neurologist who's done a lot of the original work in diagnosis. I know me as a beiges, behavioral neurology and worked in his clinic every Wednesday, which I continued on into fellowship and then became an attending for almost 16 years. And that was the memory disorder clinic for the state of Florida, saw just an amazing variety of presentations, clinical presentations, but the flip side of that was working with Leilani DoDI, who was a PhD, is a PhD in education and nursing, who was the clinic coordinator and Grant Manager for this grant funded clinic and learned just so much from her about working with the families of patients with dementia. So much of what I do is still based on what I learned with from working with Ken Heilmann and with Leilani Dodi an amazing thing. And the more I worked in that field, the more I felt connected to the patients and families. And that's kind of what led it's always an accidental kind of relationship that has grown into kind of a lifetime so far career.

Dr. Kerry Horrell: 6:41

Wow. As Bob said, we're focusing on dementia today. And I so this is not my area of expertise in any like, any way because I work with young adults and teens. Well, I don't I mean, I just I took I took neuro psych, in grad school, but this is an I did a couple it, to be honest, I did a couple full like neuro psych batteries for older adults. And the feedback was so sad. And it was so tough for me that like I pretty clearly was like, I was not cut out for this part of the work. So I have a lot of it's heartbreaking. Oh, yeah. And again, I have such I have such respect and admiration people do this. The one thing I do remember, and I'm curious if you can share a little bit more is like the term dementia, and the idea of dementia is quite complicated. Like it gets sort of lumped in with any type of just memory loss. Yeah. And, of course, like memory changes. That's one of the areas you see change as people get older. But that's different than dementia is. And it's different than Alzheimer's or Alzheimer's is a type of dementia. Anyways, I wonder if you can tell us start us off with like, what is dementia as a concept? How does this differ from other types of memory loss?

Dr. Josepha Cheong: 7:52

Yeah, absolutely. I mean, that's an important concept and question because that's, that's probably one of the main things that's asked when folks come into the memory disorder clinic, as you know, is what exactly does dementia mean? And dementia is, is a very general term that refers to memory impairment, and then an impairment of another brain functioning something that's sometimes referred to as higher cortical functions. So things multiple step things like reasoning, decision making language, both written and spoken, communication styles, visual spatial sense, having a deficit where there's a significant memory impairment can kind of give some examples, because that's, that's a question that's asked a lot is like, do I have dementia. And so the key thing is that these deficits along with the memory problem, impact on a daily basis, the ability to perform daily function, so and then there's and then they divide them up in terms of instrumental activities of daily living, and activities of daily living. So going from that an activity of daily living are the basic things, grooming, feeding toileting, dressing yourself. instrumental activities of daily living, or IADLs are things like driving, cooking, using a checkbook, paying bills, that kind of stuff. So being able to cook a meal would be an instrumental ADL, feeding yourself is an ADL. And so as memory impairment becomes more significant, associated with the ability to recognize, you know, this is a microwave, not a closet, you know, those kinds of things, that's when you start to have a degradation in daily function and that the memory problem plus the impairment of daily functioning means dementia, and then that's when you get into the different kinds of dementia. Yeah, but

Dr. Bob Boland: 9:43

let's let's before we get to that, this is a question we get a lot is like, suddenly like suddenly when you get to certain age and stuff, anytime you forget something, you're kind of worried and you kind of become sensitive to these things. Absolutely. Sounds like you're getting into the kind of like, how does this differ? I don't know if is there's such a thing as just there is normal age related memory loss my case Yeah, how many times? As we get older, we're gonna forget things more. We're gonna bury we have so many things to remember. It's just so to a point, I guess that's normal, correct? Yeah.

Dr. Josepha Cheong: 10:15

Like so for example, losing your keys for a couple hours in the house somewhere because you've misplaced them. That's normal aging, or actually just normal daily life. Thank God losing your keys and then finding them in the freezer. Not so normal, okay? And or misplacing common objects. And then assuming that somebody took them, I had one patient who was convinced that somebody had broken into her house to steal the garlic rolls out of her freezer, but then left no trace of entry and exit or anything, you know that that's so misplacing the garlic rolls, putting them in one bin in the frigerator versus the other, instead of the freezer, that's probably that's probably normal, you know, just stress throwing everything into the freezer into the fridge, as opposed to I know, I put my garlic rolls in the freezer. They're not there. Somebody took them. I know it was the guy in the trailer next door to me. Yeah, that's not normal. True story,

Dr. Kerry Horrell: 11:16

is this fair comparison, because I've actually never heard, I don't know that I've heard dementia described like this. And where my mind goes is, it's in a way, it's like depression, where like, there's the symptoms. But as far as like the etiology, and the severity, and like, where that depression is coming from, is different, but like, what dementia is, is these functional impairments. And

Dr. Josepha Cheong: 11:39

in terms of to what degree do they impact? Yeah, daily function? And then do they impact high level things? Like, be you know, you're managing multiple things? And you forget one thing? Or is it that I don't know how to button, my shirt?

Dr. Bob Boland: 11:59

No matter of degree, but also a matter of just like, of what the effect of this is, I suppose if I can't find my keys, I can't get to work. So I guess that would

Dr. Josepha Cheong: 12:08

be celebrating until they find me on Zoom. Well, another example, of course, is is that there is something that is commonly referred to as mild cognitive impairment, MCI, that's, that's where folks will come in. And they say, I know, and they are just bothered that they know they have a problem with their memory. But when you test them out, even with Dr. Herrera, what you were talking about those neuro psych batteries, and they come up within normal limits on all the neuro psych batteries, and there's no impairment of daily functioning, but there's still the subjective sense. And they do forget more things than not that's going to be considered MCI, those are the folks you kind of want to watch closely as well as rollout could there be other causes such as an underlying anxiety or depression, which can certainly impact attention? Which then will impact memory? If, if you're constantly distracted? There's a question about whether or not you can you can take in information encoded and have it as a memory as your working memory, you know, so anxiety and depression will totally disrupt that. You were

Dr. Kerry Horrell: 13:17

going to tell us about different dementias? Just

Dr. Bob Boland: 13:20

say that, let me ask you.

Dr. Kerry Horrell: 13:25

The other maybe question I want to throw in there, too, is like, how much does figuring out which type of dementia matter in regard to treatment? Yeah,

Dr. Josepha Cheong: 13:34

actually, that's a another excellent question. And that's something that was certainly the question that's asked by a lot of families when they come in, because they want to know, first, is it dementia? And then two is what can we do after that? You know, and the way to think about it is that if you have a room with 100, people with memory problems, right, the way to think about 60 to 70 of those people so 60 to 70% of all people who present with dementia probably have Alzheimer's, Alzheimer's is the most common form that we know of, of dementia, and it is mainly a diagnosis of exclusion. And then there's about 10 to 15%, which are kind of in that so Alzheimer's is in the irreversible, meaning that you can't change what's already been loss. And you really can't alter too much of how it's going to progress if this continues to progress.

Dr. Bob Boland: 14:26

And you see some exclusion, but there's there's starting to be some tests for right? Yes.

Dr. Josepha Cheong: 14:31

Yep, there are there are genotyping, but a lot of it is based on history. Plus you want to do the neuro imaging is always going to be key in this. The next category, which you really want to carefully carefully screened for is vascular dementia is folks who have memory issues and dementia because of strokes, because those can actually be going to rehab to a certain extent Plus, you can also stop or slow the progression. By treating the underlying cause so for the most common causes of of these are going to be issues like high blood pressure, high cholesterol, inactivity, basically poor overall health, cardiovascular health puts you at risk for that. And that's about 10 to 15% of folks who present with dementia. And then there's the other remaining category of about 10, another 15 to 20%, which are other and this is where you have some of the newer identified they've always been around, but theirs is just they were always lumped under Alzheimer's, but now they're breaking them out into Frontotemporal dementia, which is more famous, mostly known for now because Bruce Willis, his family has has has announced that Lewy body dementia, which is is really different presentation where they have the memory things associated with Alzheimer's, but some of the movement issues of patients with Parkinson's disease

Dr. Bob Boland: 15:59

is in psychiatry is favorite one, right? Because it has like hallucinations. It's

Dr. Josepha Cheong: 16:03

got hallucinations. In fact, interestingly enough, even before all the memory issues and before the movement disorder issues, if you look far back enough, there's usually an a significant episode of depression, and also hallucinations and some paranoia today.

Dr. Kerry Horrell: 16:21

Isn't that what Robin Williams died from? She you know, I

Dr. Josepha Cheong: 16:27

don't know is I want it. Well, I

Dr. Kerry Horrell: 16:29

want to say because he's

Dr. Bob Boland: 16:31

socially died from suicide, but he Well, that

Dr. Kerry Horrell: 16:35

I was gonna say, I think socially Of course, like he's a very popular case of Yeah, I think his his wife, his wife, I think has made a big, it's really tried to to use her platform to educate that she really sees him dying from a dementia rather than from suicide and that it was a result of psychosis dementia. Yeah. And he

Dr. Josepha Cheong: 16:55

progressed, one of the key things about all of these other progressive dementia is like Lewy Body, frontotemporal they progress much more quickly than Alzheimer's. So So for example, at the time of diagnosis, a person with Alzheimer's disease probably had the dementia for at least four to seven years. That's the average time that someone has had the process. And it's in usually, you can predict that they will have they will continue with it for seven to 10 years, my longest lived patient had it for 25 years post diagnosis that took care of him and his family because it dementia, that's the other thing if I can interject dementia, never just an illness of the patient always have to take into account the family, the support system, the caregiver, particularly the primary caregiver, 73% of which are almost always women. So the burden of care for patients with dementia is on women. This is an illness that really has some implications with regard to, you know, social things. Yeah, you know, it's African Americans are twice as likely to develop dementia, Alzheimer's, Hispanics and Latinos 1.5 times compared to Caucasian populations, and then women's that might be or do social determinants of health care, access to health care, the kind of the attitudes that prevent folks from coming in for care, because they have, they're worried about the system. And you know, there's a suspicion of if going to a health care provider that does not, may not understand me, if I'm not of the same ethnicity or culture, I'm less likely. I mean, it's, it's apparent, you know, there's this old joke that I'm Chinese, there's a comedian out there that says, you know, Chinese parents, they always say you'd be a doctor, you'd be a doctor, you'd be a doctor, and they say that all the time. But believe it or not, Asian parents are the hardest ones to get to the physician. They won't go there like all doctors don't know anything.

Dr. Bob Boland: 19:06

This feels like a pretty ramp and a lot of people I know.

Dr. Kerry Horrell: 19:11

This feels like a nice segue, though, into the some of what we wanted to talk about today, which is how having a person in your family with dementia, gosh, just like impacts the whole family the system, if you will, and especially around the holidays, with with so much travel, trying to make plans. You know, I will say to share a little bit for a second I My grandmother had Alzheimer's and she actually she died of cancer, which was having a person who had pretty severe Alzheimer's and was had cancer was a really tough combination. As a kid it was. I didn't understand a lot of it, but I know it was really sad to watch. I know it's really tough on my parents. And so, again, I think I remember those years when she was in a care facility. We didn't travel for the holidays. because it was like what are we, you know, like this was just such a huge factor. So again, I'm, I really appreciate the idea of us talking about this because this is a reality for so many families. And so I wonder if we can start with a, what have you noticed in regard to how dementia impacts people, the individual and the system during the holidays.

Dr. Josepha Cheong: 20:19

I mean, as wonderful as the holidays are, I mean, they are stressful. In general, there's just a lot of for the person with regular cognitive functioning is a lot more sensory stimulation activity, there's tons of changes in routine, and routine, routine routine, those that principle of having a routine, doing the same thing every day, etc. That is key to the management of the world of a person with dementia. And that the burden on for maintaining that routine really falls on a caregiver, the majority of patients with dementia are cared for in the home, and by non professional caregivers, such as family, usually a spouse, or an adult child. And it's so important, you can tell how a person with dementia is going to do by really watching the caregiver and keeping a real close communication line of communication are open with the caregiver. Because they're highly, they're more prone to developing anxiety, depression, they're at risk of increase sick days from work, which then puts financial pressure than they tend to, because of their commitments to caregiving. They will often have losses in their social context, and their social world. I remember one couple I took care of very active, I used to travel the world, etc. I didn't meet them till they were in their 70s and showed up at a depression screening event. And it was the the husband came in and was screened for depression and brought his wife along and she was she was delightful to bear. But even then, when I knew that when I was interviewing him, she was I had the sense that she was probably in mid to moderate stage of dementia. And it was really interesting and and he was pretty severely depressed. And it came to that he acknowledged the loss of the ability to do the things he liked to do. He used to golf all the time used to travel, but he didn't feel comfortable leaving them. So what they did then had a mobile home because then he goes at least I can take my wife and the dog. And it's always the same place. So he'd already figured these things out that as long as he kept things routine, and it got to be where they couldn't come to the hospital anymore, because it was just too overwhelming. So he used to drive by in his camper. And I would just wait at the curb hop in and do my evaluation and

Dr. Bob Boland: 22:54

therapy session on wheels. Yeah, exactly. And

Dr. Josepha Cheong: 22:57

this was like, yeah, 20 years ago, and we did this for years. But it's a whole idea that caregiving is stressful. And so the better the caregiver does, the better the patient will do. And it's one of the things that I always recommend that in our clinic. And again, I learned this from Dr. Dodi is that right up front, you sit with the caregiver alone and just say, Look, I'm about to tell you some very tough things about what's probably going to happen. And this is what you need to do. And one of the things we used to always end with is that the best thing you can do for him or her, your wife, your brother, your sister, your your mom, your dad, because you're the caregiver, the best thing you can do for taking care of them is to take care of yourself, make sure it's permission giving, giving them that thing and then trying to figure out what support systems are available through the local community and or associations. And, you know, I'll give some hints on that. But the holidays in particular for for anyone is is difficult for for folks taking care of someone with dementia travel in particular and you know, have a have a realistic expectation, how important is the travel and the end goal compared to how distressing Do you think it will be to the person? And here's

Dr. Bob Boland: 24:18

example she just you know, it's like you just didn't travel? It sounds like and that seems like the simplest thing. Yeah, some families don't have much choice, right? So

Dr. Josepha Cheong: 24:26

Correct. Some families don't have choice and and like I said for folks, except for the ones with the most severe forms of dementia or the severe end stages of dementia. You can travel it just takes a lot of planning and the way I I always kind of preface it is like, you know, did you raise kids? Do you remember what it was like traveling with a three to seven year old and that's how you want to plan you want to keep two things in mind that seem almost opposite. You want to have routines, and you want to be flexible, and which kind of seem so they're always in the balance. You and you're using routines and flexibility to ensure safety always and then comfort. And so there's a number of things build in time, wherever you're going to go. However, it's going to take you to get there, make sure you have time for frequent breaks. I remember talking to the family of one patient. And it was really wonderful because they had grandkids that were visiting in their late teens and mid or late teens. And they were going to then drive up to some mid atlantic state. And one of the things I told the husband of the patient was like, a sign one of the grandkids, sit in the backseat with her and go through pictures, you know, some to keep her occupied. But then also, make sure you have snacks and hydration, because hydration is a key in older adults, in all older adults, but in particular, those with dementia, because even mild dehydration can really exacerbate fatigue and continue

Dr. Kerry Horrell: 26:01

that.

Dr. Bob Boland: 26:02

That's interesting, right? It's probably naturally dehydrating anyway,

Dr. Josepha Cheong: 26:06

oh, yeah, yeah. And it's, there's the usual kind of worry that a lot of older adults have is that, well, I don't want to drink too much. Because I don't want to have to keep finding a bathroom. You know, what if I can't find a bathroom, and that's a major thing that keeps people in their house that keeps them from traveling is I don't like using public restrooms, to find it. And that's the thing, it's really wonderful over the past decade how family restrooms are now available in most places. And that can be so helpful, you know, pack an extra set of clothing, and underwear, because accidents do happen. And wherever you wherever it is that you are going, when you get there, make sure to kind of find a quiet space for them. So that if if being with 21 family members gets overwhelming, there's like a small side room, or an alcove in the kitchen somewhere where they can still be part of the activity, but still have a little bit of downtime, as well as activities that engage them. So for example, if, if it's a person, if it's a person who always participated in the making of the big meal, the cooking and stuff like that, maybe they can't handle the preparation of the turkey and everything or baking the cookies or whatever, but they can at least be participating in mixing ingredients, you know, with supervision, setting the table. Again, grandkids are great for this I always assigned, you know, I was telling him assign one of your grandkids to kind of be the assistant, you know, they're all elves at Christmas time. Anybody under forefoot is an elf it's the way I used to kind of advise, you know, and make it interactive. Don't shut them out, like oh, no, no, no, just sit there. It's it's after have to include them. I have to give, everybody's got to have something to do because then they're engaged. And it's also stimulating. You know, it's cognitively stimulating to be in an activity. So other things puzzles are really great. Assign one of the elves to help with the puzzles, looking at old photographs. Yeah, who is that? You know, do you remember this person? That kind of thing? Reminiscence is a good thing. Music is wonderful. And it's really, it's really impressive how people come alive. One

Dr. Kerry Horrell: 28:32

of the things that I'm first of all the respect and care and dignity in which you speak, this population is so profound and clear. And I'm just wanting to know and share some gratitude for that. Because I think that that's, yeah, that's just such an important piece that you're saying, like, how do we pay? How do we just talk about the realities of some of this? Yeah, how do we, you know, take care of people the best when they're in the season of life, and especially those who have an impairment. One thing I'm thinking about too, is, I don't have kids yet. But when I have kids, I think one of the values I'd love to teach my kids about is like, learning from lots of different people, and including people who are at a different stage of life. And I love this idea of like, how do you use those moments of like, what can you learn from, you know, grandma, grandpa uncle at this moment, like, what can you give music or traditions or things about their family? They just really love that. I think that sounds like again, such great advice and like,

Dr. Josepha Cheong: 29:27

Yeah, I mean, in fact, you can prompt them with simple questions. Like, where's the favorite place you've ever been? Or tell me about what you like to cook? The most, you know, things that are specific to them. Doing things even as simple as folding laundry together, is kind of is is that's therapeutic. You know, the involvement, working with plants, gardening, being outside is great. As long as you maintain safety, you know, no falls because falls are are bad. There's there's no other way to every time I say the word bad, falls are bad. And so, but assigning kids and grandkids again, I mean, I've referred to them as elves. I don't mean that disrespectfully. I mean that in the best way possible is, you know, assigning them as a urinal. And your job is to do X, you know, and you can prompt them.

Dr. Kerry Horrell: 30:26

Do you have advice for? Like, I think one of the things that I've heard from my patients who are a bit younger, or even just people in my life is like, maybe like, so these are the people trying to care for someone who might be going through a dementia. There's like a level of frustration over like the repeating stories, repeating jokes, repeating themselves asking the same thing. And just getting that point of like, you've asked this 10 times, I'm really fed up like, I wonder what advice you have for those moments? And how to handle that. Do you draw attention to do not do just? Yes, that's

Dr. Josepha Cheong: 30:57

it's that's probably the most common thing that wears on a caregiver. And one of the things to keep in mind is to before, and I've also heard that this is the advice that for anybody who's married, who wants to stay happily married is never say the first second or third thing. That's one thing is just that pause. But also to think of it in this way, the customer may not always be right, but they're never wrong. And so you create this, this no fail environment is a term that's commonly used and that the person with dementia who's repeating Oh, this is such a lovely day, when can we go out in an even if they asked in the 15th time, just think of a way to redirect? Oh, I think that's yeah, that's a great idea. But right now, why don't we, why don't we sit down for breakfast? And why don't it's a no avail environment is because that's, that's a really good story. But before we start on that, let's do this or distraction, a distraction, you redirect, have a thing of redirecting. The other thing is that when folks ask a question, or say the same thing, again, what they're looking for is an acknowledgement, you know, that may be to them, it's the first time they're selling you and this guy, wow, that's really sweet. And just have a really good positive kind of, and it's everything is reflected. So always say it with a positive aspect and bright, and that can be enough to engage them in something else. But it is direction. This

Dr. Kerry Horrell: 32:35

is a bit of a personal story, but Vail and my grandma was kind of in the end stages of her life, she would retell the same joke about what kind of It wasn't even a joke was more like a fun fact, of which cars get pulled over the most on the freeway. And you know, what's funny is she would, she would sometimes say red, and then sometimes say black, and she would change her answers. And so then for my sister, and I became sort of like a little, you know, like, not in like, we weren't teasing her, but we were like, I wonder which one Grandma's gonna say, and it's actually a very fond memory now, for me of my grandma.

Dr. Josepha Cheong: 33:05

And that's, that's the thing, those are the things that families will remember, you know, and, and to be able to, because one of the things to understand to, I always have to remind myself when I'm working with someone with dementia, is that their world is shrinking. So I'm thinking of my patients, I used to travel the world and you know, do all this stuff. And now she can't anymore in there because her her husband can't anymore because she can't anymore. Her world shrinks to the interior of their home. And, and their their campervan, you know, and so, for them, that's their entire world, and you want to make that world as comfortable and as happy and as as good as possible. But, but also acknowledge that there is some frustration, and sometimes it's important to do not only the redirection, but also changing set, there can be a time when they they have something known as a catastrophic reaction will something will just set them off, you know, either with being upset, it's like a tantrum in a small child. And, and because this is not a small child, it's a 70 year old, 65 year old, 80 year old adult, it's hard sometimes for those of us around them not to react, like snap out of it, when in fact they can't. And so the reverse of that is always asking, how would I react to this? If, if my five year old came up to me and told me, Hey, Mom, you know, do you know what they call a, you know, a dinosaur with blue spots? And it was like, Okay, I've heard this like 50 million times, but I think it's cute. When it's someone who's 85 telling you the same thing. We kind of don't have the same reaction. And I wonder why. It's because we keep wanting folks, family members caregivers are kind of dealing with their own grief. Yeah, yeah. Yeah, yeah. So to be sensitive to that reef wasn't

Dr. Kerry Horrell: 35:03

totally the word on my mind When you were just saying that like when it's a kid. Yeah, it's delight. Yeah. When it's somebody who's older it is it's like, we're

Dr. Josepha Cheong: 35:11

gonna grow out of it. And yeah, they're gonna grow out of it to the extent that we wish that they would ask us, what do you call a dinosaur with? Exactly

Dr. Bob Boland: 35:18

someday you'll never get that anymore. Yeah, exactly. Right. Well, so can you recommend like resources? I mean, because like, I don't I hope is there for people who are dealing with this, because it seems very hard to do it if you're doing it alone, or with just a small family. Absolutely.

Dr. Josepha Cheong: 35:34

And thank goodness for the internet. You know, I know that the Internet brings in Dr. Google, but for for families of patients with dementia, the internet is I think, literally a godsend, because it can be their connection. And then now with telemental health, it's a real godsend. But I have what I always call my my emergency first aid kit for caregivers of patients with dementia. And this is something that that I do every single time I meet with a patient and a family is I give them three recommendations. The first one is this wonderful book, which is almost in its 40th year or 35th year, but it's the 36 hour day, which is a book and I think it should just be given out for free. I wish there was a way to get a grant and just give a copy to everybody. You know, 36 hour day basically works like a user's manual for family members of people with dementia. You can get it from Amazon. It's been translated into 30 different languages. The current authors, it's always Peter ravens, who's up at Johns Hopkins, but is a gator. Go Gators Go Gators. And a new author mace. And it's just a wonderful book. It's chock full, I recommend it to everybody. And every library has copies of it. Every hospital has copies of it. Another great resource is the Alzheimer's Association website, just Google Alzheimer's Association. They have a section on explanations and everything. But they have a really wonderful section on tips for caregivers to take care of themselves as well as what do I do if you know and then the the third one that I I just I love this person. And what she's done. She is a retired occupational therapists who retired and dedicated her entire life to taking care of her mom, who had Alzheimer's. And then this grew into this whole business and brand is Tepa, T e, t E P A snow s n o w Teepa snow.com. And it's it's every thing to know how to manage a person with dementia, who is crying, who is upset, who grabs who screams and basically non pharmacological management for behaviors associated with dementia, it is just an amazing work that she's done life's work, there are courses, there's ways to be certified. And she's got a bunch of free open access YouTube, like how to manage if a person with dementia grabbed you how to react to that how to Yeah, it's really I mean, I, I am not associated I, I do not know her I attended. I've attended lectures by her. And I just think she's amazing. Amazing. And the the website, I mean, it is life's work. It's just amazing. But these are the three I always tell people and families will come back and say, you know, that was really helpful or not and just go through. Yeah, that kind of thing. All right,

Dr. Bob Boland: 38:46

last question it, you know, there's more treatments coming out for dementia, we haven't really talked about the meds, I don't think we're gonna have time for that other way, and I'm not the person for that

Dr. Josepha Cheong: 38:56

I can recommend you are

Dr. Bob Boland: 38:57

you know, more than most of us? Would be great for that. But yeah, he's great. Do you think there's, we're gonna see like cures for these things in our lifetime?

Dr. Josepha Cheong: 39:06

I hope so. And I think that with the advent of AI, and big data, I think that's where it's going to come from is earlier diagnosis, which sounds really distressing. In fact, oh, gosh, who's that actor, Thor, Chris Hemsworth. You know, because he was doing a television show, one of the things that he had to do was was genetic testing for dementia, because his whole thing is about wellness, health, etc. And how to take care of yourself as you roll. Do they have to do that? Yeah, I know it was the show. And he found out that if I'm not mistaken, he found out that he's he's he's got a genetic predisposition. Yeah, yeah. His his family. I mean, his parents are super healthy the whole bit but again, these are not confidentiality issues, because I mean, this this was in the popular press. And

Dr. Bob Boland: 39:53

it no no, Chris Hemsworth personally, no,

Dr. Josepha Cheong: 39:56

I don't if I did, I wouldn't let you know Actually the brothers are pretty cute. Agreed?

Dr. Kerry Horrell: 40:03

Yeah,

Dr. Josepha Cheong: 40:03

I know. We do. But we digress. Yeah, one of the key thing is I do think so I think we are getting closer. One thing I would like to say is that anti-psychotics are not the answer. So and before anybody with dementia is placed on an antipsychotic, please be sure there's only been one that has been FDA resulted in Yeah, there's only one that's been FDA approved. But even then I would so caution, because most of it is non pharmacological management. And then with the monoclonal antibodies, that's they're they they're showing promising, but there are risks associated as well as costs person best to talk about that if you really want someone to talk about that. I think that Brent Forster is one of the one of the key people he's kind of my guy, him or Icom, as they call them. I think that AI and big data are going to help us identify people earlier. And so there's that idea that maybe we can decrease. If we can identify people earlier. Can we? Can we modify those risk factors that if we didn't know about them till much later, can change? So, but I certainly hope so. But you're ascending, you're optimistic? Oh, yeah, I have to be because I'm aging. I want to be optimistic. Otherwise, I've already given my husband a series of things to do and not do when I become demented. Although, I think it's gonna be very hard to tell, because right now, I've gotten a lot of memory stuff, and I lose keys all the time. But I think that's maybe that may be psychological.

Dr. Kerry Horrell: 41:42

To you, you are an amazing person. And I just want to again, say, your compassion, your compassion, and your thoughtfulness is really clear. And I just really appreciate you coming in not only sharing with us, but like this is this is a really great episode, I think in regard to like, many people, not just providers or other mental health people like will benefit from because again, having come from a family where this dementia impacted my family, like

Dr. Bob Boland: 42:06

I just feel backs most families, I think, yeah, yeah.

Dr. Kerry Horrell: 42:10

So thank you so much for coming

Dr. Josepha Cheong: 42:12

on to appreciate that. Thanks

Dr. Bob Boland: 42:14

so much.

Dr. Josepha Cheong: 42:15

It's a privilege. All right.

Dr. Bob Boland: 42:17

Thanks for listening to the mind dive podcast. You've been listening to Dr. Josepha Chong, and I'm your host Bob Boland.

Dr. Kerry Horrell: 42:24

And I'm Dr. Kerry Horrell and thanks for diving in. The mind dive podcast is presented by the Menninger Clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen. For

Dr. Bob Boland: 42:38

more episodes like this, visit www dot Menninger clinic.org. To

Dr. Kerry Horrell: 42:43

submit a topic for discussion, send us an email at podcast@menninger.edu