The ceremony of innocence is drowned

Every so often, things are not as they seem. Perhaps that should come as no surprise to an ever-curious septuagenarian, but sometimes I realize I have been misled, lulled into a sense of complacency by the reigning Weltanschauung; or, to be clear, the previous one -the one in which I received my formal education. But that’s the joy of travelling along different routes, isn’t it? The perspective cannot help but change; what once was a view of rocky cliffs and snow-laden peaks becomes a rolling carpet of trees -like a book in which you’ve turned a page to a different story. Things that made sense in a land of bare and craggy rocks are suddenly wearing different clothes.

Zeitgeist is like that though, right? It evolves with time and circumstance, and with each change comes new understanding, a fresh appreciation of how we evaluate the world around us. It keeps us on our toes; it’s how we progress. So I felt a sense of gratitude when a discrepancy was pointed out with something that I had long ago thought had been settled by observation: the gendered frequency of dementia. When I was going through medical school, the perceived wisdom, and one that seemed borne out by statistics, was that women were at greater risk for dementia. However, Kate Gregorevic, a geriatrician with PhD in the psychosocial factors of frailty in older adults, offered a different perspective -one I had never considered before. In an interesting essay, she wondered how she could possibly compare ‘a retired, 80-year-old male academic with an 80-year-old woman who had only two years of education because she lived through the Greek civil war? How do I compare a woman who does all the shopping, cleaning and cooking in her household, with a man whose social role is to be served by this woman?’ A fair point to be sure.

As she points out, ‘for most people dementia is not a strictly genetic disease, it’s related to lifestyle and factors that we don’t yet understand… it’s based on my subjective judgment that the person’s cognition has declined to the point that they can no longer fulfil their social role.’ And therein lies the complexity; unlike chromosomal sex, ‘Gender is a cultural construct that men and women have defined social roles based on these biological attributes.’ And for most older people, the prevailing cultural assignation was their only option. Still, many of the dementia studies used risk factors assessed by ‘a screening test called the mini-mental state examination (MMSE), which is heavily influenced by education level. Since women have traditionally had lower levels of education and the study didn’t adjust for this, were these women more likely to have dementia, or were they just bad at the test?’

Unfortunately ‘one seemingly simple question we don’t know the answer to is how many people are actually living with dementia and how many are women; because around 50 per cent of people living with dementia are undiagnosed, all we have are estimates… While dementia is not a normal part of ageing, the biggest risk for getting dementia is simply getting older, and since, worldwide, women have a longer life expectancy than men… more women reach their 80s and 90s when dementia risk rises.’ Maybe men are dying too young to be at an equal risk.

Gregorevic suggests, too, that ‘Many women in mid-life experience brain fog, or functional cognitive disorder, especially trouble with concentration and memory. Some women do experience a decline in memory and processing speed during the time of menopause, but these changes [usually] resolve once the hormonal changes have settled… Menopause can negatively impact sleep, which impacts cognitive function, and is also a risky time for the onset of depression. So many women who experience this brain fog are terrified that this is the start of dementia.’ But is it really related to hormonal changes? Well, there is some evidence that ‘an early dip in oestrogen from oophorectomy (removal of the ovaries) is a risk factor for the development of dementia, as is an earlier onset of menopause. This might or might not be purely the effect of the oestrogen on the brain because, when women lose the protective effects of oestrogen on cardiovascular health, this can also impact the health of the blood vessels in the brain.’

But, forgetfulness is not necessarily dementia. ‘Some get marked language impairment early, still able to follow well-known processes, but not able to find the words to name common objects and people. Other people can become apathetic, able to perform well on simple memory tests, but with no drive at all to undertake personal care. Some develop personality change, becoming labile and easily irritated.’

Still, in the older female who has perhaps had a different personal life than today’s woman -different expectations, different responsibilities, and different opportunities – it might be difficult to compare the aspirations and memories to a male of the same age.

Although my own limited experience no doubt looks at things through the hopeful and jaundiced eyes of an aging male, I can remember visiting my aunt and uncle many years ago when I was away from home and still at medical school. She was a great cook, and I, understandably, was a grateful eater. I enjoyed their company, but hadn’t seen them for over a year. My uncle was a superb raconteur although he was then in his early eighties. He was a retired English professor, and Auntie Liz, in her nineties by then, had been a sociology professor at the same university -I think it was where they’d met.

But on that visit, Uncle Walt had seemed unusually clumsy at the table, and, although he’d smiled a lot, hardly said a word throughout the meal. Right after dinner, he’d excused himself -he was tired he said- and thought he’d lie down for a while.

But it did nothing to dampen my aunt.

“You sit right there, G,” she said, rising from the table and disappearing into the kitchen. “I made your favourite pie for dessert,” I heard her yell from the other room. “Ice cream on it as usual…?” she added, coming back to the table with a huge piece of pie smothered with vanilla ice cream. “I don’t  know why I even ask anymore,” said, chuckling to herself.

“Is Uncle Walt okay?” I asked as I dug into the pie. “He’s usually so talkative -always has a new story to tell…”

She hesitated for a moment before replying. “Walt’s fine,” she said, but I could hear a little change in her voice. “A little forgetful nowadays, but no, he’s not sick… He gets tired easily -his age is showing…”

She saw me staring at my plate; she could tell I was sensing something, I suppose.

She pretended it was about the pie. “There’s plenty more in the kitchen. Do you want another piece?”

I shook my head. Maybe my student doctor role was beginning to surface; I don’t think I looked sufficiently convinced at her explanation about Uncle Walt. “What do you mean ‘forgetful’, Auntie?” I blurted before I thought about it, and immediately felt embarrassed for putting her on the spot.

She sighed and sent her eyes to explore my face. “I mean it’s getting worse, G… But we manage.”

“Has…” I desperately groped for the right words. “Has he seen anybody about it…?”

Her eyes stabbed briefly into my cheek, and then softened to a caress. “No… There’s no need, sweetheart . There’s nothing anybody can do for him that I can’t… Anyway, he trusts me…”

I stared at my plate again, uncertain of what to say. Finally, I managed to look at her. “Well, Auntie, if there’s anything I can do to help… I mean, I’m in the same city as you now…”

She smiled and reached across the table to squeeze my hand. “Just show him you still love him, G. That’s what he needs now…”

I think she was right. It’s what we all need – especially when we’re lost…

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