A young boy named Hudson greets us at the door, donning an Edmonton Oilers jersey featuring his favorite player, Ryan Nugent-Hopkins. Right behind him is his sister, Katrina, their mother Colleen, their gido (grandfather in Ukranian) Elmer, and grandma/Elmer’s wife, Pam. Elmer isn’t wearing his neatly tucked, bright green John Deere shirt like last time we met, but the suspenders holding up his slacks remain a charming feature.
Born in 1946 in a Ukrainian community near Edmonton, Elmer spoke only Ukrainian. “Until grade 3 I went to school and I couldn’t speak English.” He continued formal education until Grade 8, then left to work and raise a family with his wife, Pam. They married when they were 19.
“If there’s one thing when I met Elmer that I knew right away, and that I noticed right away, is how good he was with his hands and how quickly he learned by watching somebody,” Pam said. “His hands were always busy and his brain was always wanting to watch and learn more.”
“I don’t know that there’s ever been any kind of practical problem my dad couldn’t solve,” Colleen recalled. “If anything ever went wrong, I [would] call my dad.” They regaled us with stories of wasps in heat registers and birds in chimneys, always with a creative solution to the issue. When asked how he learned these creative solutions, Colleen said it was “By having some accidents.” Pam told the story of when he was cutting down a tree that fell onto a tractor, breaking the steering wheel. “That was a… misjudgement.” Elmer quipped, setting the room alight with laughter. Once he was even able to haggle for goods in Cuba by giving them the shoes off his feet. Seriously.
“[Pam] encouraged him to go to school because he was so handy with things, and so he became a mechanic. And then a few years later he opened his own radiator shop. He worked hard and did really well for himself,” Colleen told us of Elmer’s youth. But life can throw a mean curveball, and he had a heart attack when he was 44. He re-evaluated things and thought, “You know, life is short and this is a stressful job, and so I sold the business to my son [Wes] and retired.” Colleen added “Then after that he watched soap operas for about a year until mom was ready to kill him,” causing everyone to burst into laughter again. “That’s one of the hard things now, because [keeping his hands busy was] where his enjoyment was, where his learning was. Now with his vision impaired and his pacemaker and cognitive difficulties, people can say, ‘well you can do puzzles, you can read.’ Well, that’s not his thing. He finds little enjoyment in that.”
Elmer suffered a major stroke just a couple of months ago, but it was one that left him with very few physical deficits, and certainly no obvious ones. His language skills were left largely intact as well, so if you stopped Elmer in the street for a quick chat, you might not notice a thing. Despite this, his difficulties are marked. His short-term memory is sometimes only seconds long, and his ability to orient himself in space is drastically reduced. He used to spend long days puttering around his acres of property, and now he’s gotten lost trying to walk down the block. It’s rendered him dependent for many of his activities of daily living, and driving, unfortunately, is no longer an option moving forward. “I think the loss of independence is tough, and the confusion,” Colleen mentioned, “Sometimes he can walk to the park and follow conversations, like I think right now he’s pretty sharp and following it. But one day mom said he couldn’t find the deck in the house.”
When people think of Alzheimer’s and other forms of dementia, it’s generally thought of as a gradual process. In Elmer’s case it’s due to vascular dementia, caused by an ischemic (restricted blood supply) stroke. “For Dad it was literally overnight. [He] went from full cognitive abilities to not. You can never be prepared for that, but certainly I think we need to have more resources in place,” Colleen commented. “I remember hearing the summer before he had his stroke how fewer people were dying from strokes. But of course, the other side of that is the long-term disability that comes with it. [A] pamphlet said 20-30 or 30-40% [of people] never drive again. It’s difficult.”
“The backstory is that mom and dad divorced [in 2013],” Colleen added, “Then in 2014 he moved in with a girlfriend, but right after the stroke their relationship became strained because she didn’t sign on [to the challenges of being] the caregiver.” Initially, his girlfriend was reassured by the possibility of major recovery, an often unpredictable feature of strokes. Still, the frustrations from Colleen were clear. “Why can’t you just say he has visual and cognitive defects. [Major recovery is] unlikely, and maybe it will happen, but let’s make a plan for if it doesn’t.”
Shortly after the stroke, Elmer asked Colleen how Pam was doing, and from there it started anew. “The stroke I think also made him more emotionally accessible,” Colleen affectionately said. “He’s a man of a certain generation – very stoic, doesn’t talk about feelings, and now he’s much more emotional and demonstrative with his feelings and physical affection than he was.” Pam added, “He doesn’t remember the divorce. He was very shocked when I [told him] one day and he looked at me and said, ‘Don’t say that.’ So, we’re not divorced; we’re living together in sin,” Pam concluded, eliciting laughter from the entire room.
He’s a man of a certain generation – very stoic, doesn’t talk about feelings, and now he’s much more emotional and demonstrative with his feelings and physical affection.
Colleen later mentioned that visiting the Leduc West Antique society, an organization Elmer used to contribute to significantly, was challenging for everyone. “[He] was extremely sad and emotional about what he is leaving behind and the destruction of his capabilities.” Talking about his experience living with vascular dementia was difficult for him too. With tears welling up, he said “It’s tough, you know. If I kick the bucket tomorrow, you guys will be okay for a few years. I’m just saying, it’s tough. [But] I’ve got a good support group. I’m very thankful for it,” Elmer said of his family. Colleen is grateful that they have the financial, emotional, and intellectual resources that they do. “It’s like a full-time job, almost… Most people wouldn’t have all those resources we are so fortunate to have.”
With his final thoughts, Elmer had this to say: “I think it would be interesting for people to see that things can go ahead, not backward. And I think it’s very important in life for people to see this. I think we’ll come out okay.” At that moment, his granddaughter Katrina poked her head in and asked if he would be alright if she could come give gido a hug. With a family like this, and some reframing of what makes you valuable as a person, it seems like things will come out just fine, Elmer.
Part of the diagnosis of dementia requires the cognitive (not physical) deficits to be severe enough to interfere with activities of daily living. The basic activities of daily living focus on the ability to manage self care, and include bathing, toileting, personal hygiene/grooming, dressing, feeding, mobilizing, and being able to transfer from one position to another (e.g. out of bed). Instrumental activities are those beyond self-care that are required to live independently in the community. They include preparing meals, house/yard work, taking medications as prescribed, taking transportation or driving, managing basic finances, shopping for groceries and supplies, and using the telephone or another form of communication.
Vascular dementia is a poorly defined, poorly understood subtype of dementia that can present with variable clinical features. In simple terms, it is defined as “cognitive impairment that is caused by vascular (blood vessel) factors.” Although it might be thought it would be associated with other vascular risk factors that one might find in someone with heart disease, such as high blood pressure or diabetes, current evidence is not compelling. Despite the limitations in defining or diagnosing vascular dementia, it is recognized as the second most common type of dementia behind Alzheimer’s. It may be associated with a major stroke, or occur as a possible consequence of many silent or “mini-strokes.” Deficits are sudden with a major stroke but can be more gradual and unrecognized with silent strokes, especially since memory impairment tends to occur much later in vascular dementia compared to Alzheimer’s. When features of both Alzheimer and vascular dementia occur together, it is referred to as mixed dementia.
As many as two thirds of patients who suffer a stroke have some type of cognitive impairment. Risk factors for developing cognitive impairment post-stroke include age, diabetes, prior strokes, atrial fibrillation (a type of irregular heartbeat), stroke severity, lower education, and prior cognitive impairment. There is also evidence that high blood pressure, smoking, and physical inactivity may be associated. It is estimated that only 16-20% of those with cognitive impairment post-stroke recover, with most recovery in the first 3 months.
Hachinski V, Iadecola C, Petersen RC, et al. National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards. Stroke 2006; 37:2220.
Teasell R, Hussein N. The 2016 Stroke Rehabilitation Clinician Handbook – Cognitive Rehabilitation. The Heart and Stroke Foundation.