How Do I Care for Those with Dementia?

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Dr. John Dunlop: You’re listening to TGC Q&A podcast from the Gospel Coalition. And this is the Christians in Healthcare Series, where we will seek to answer your questions at the intersection of faith and medicine. My name is Dr. John Dunlop, and I am a geriatrician that practices medicine.

Today, we’ll be talking about one of the more difficult areas that we encounter in the end of life, and that is dementia. So often spoken of as a tragedy and a heartbreak, but we need to try to understand dementia in the context of God’s word.

One of the questions we received about the end of life is what is the hardest part about the effects of dementia? Dementia is tough, but I’m often reminded of what Paul said in the book of Acts, it’s not without tribulation that we will enter the kingdom of God. And dementia is certainly one of the more difficult things that we deal with at the end of life. There’s so often associated with it a loss of hope, a loss of hope of things ever getting better, ever going back to normal. And it’s so hard to accept that things are likely going to continue to get worse. There’s the challenge of the loss of relationship, particularly for a spouse. Not being able to relate to your closest companion over the years is so frustrating. And then there’s the disintegration and change in personality. People with dementia just so often don’t behave like they used to. They’re irritable, they’re cantankerous, they have trouble communicating and they get frustrated, they get depressed. And those personality changes just make it so much more difficult.

I did a master’s degree in bioethics 20 years ago, and I started to get interested a little bit in this and decided to write a paper on what is God’s purpose in dementia? And I remember talking to a friend at church telling him that I was starting to think about that. And he said, “Well, John, what are you going to say?” And I said, “Well, I don’t know, but it’s going to be short.” And now 15 years later, I’ve written a whole book on that area entitled Finding Grace in the Face of Dementia, just how can we view dimension the context of a loving, strong, and powerful God.

Second question that came along with this was what hope is for those who have it and for their families? And that’s also a challenge. But I start with an answer saying that God is in control. God is sovereign and God is powerful and God is loving. I love Psalm 62, the last two verses. God has spoken twice, twice have I heard this, that power belongs to God and that you, oh Lord, belong steadfast love. God is powerful and God is loving. And as we look at dementia, if we’re ever going to be able to come to grips with it, I think we need to understand, yes, God is powerful, he could have prevented this. He is loving; it’s not because he doesn’t love us that this happens. And then I turn over a few pages in the Psalms to Psalm 57 verse 2 where the psalmist says, “I cry out to God most high, to God who fulfills his purpose for me.” There are times in life when we cry out to God, we’re miserable, God help me. Help me understand this, give me strength to get through it. But even while we were lamenting, while we’re crying out to God, we still recognize that He has purpose. And He does have purpose into dementia.

What are those? Well, I start by thinking about who we are as people. And go back to Genesis one, and it says that God made us in his own image and likeness. And then in Genesis two, it says he breathed into us as human beings the breath of God. Made in his image, enlivened by his breath means that we are all as human beings created with a dignity that is inherent. We don’t earn our dignity. We have dignity because we’re human beings made in God’s image enlivened by his breath. And that is the basis of my approach to people with dementia, to realize that even though the image of God is not very well reflected, it still imparts to these people a profound dignity, which I am privileged to be able to respect. And that dignity was certainly defaced and damaged by the fall into sin. We don’t reflect God in the way we were intended to, but we still have that dignity. And I’m impressed, in the book of James chapter three, it talks about people who are really jerks, people we would love to just cuss out, and it says they are made in God’s image. So our dignity is not something we earn, it’s something bequeathed on us by our creator.

And the other thing that I think that we need to understand is that all people share equally in the image of God. It was said in a different context, of course, by Martin Luther King, who said that there were no gradations in the image of God, that everybody has the same image and has the same dignity imparted by being made in that image. So yes, it’s hard to look at dementia. There’s no good reason to expect improvement in this life, but we can take confidence that God is loving, God is strong, that he has purposes, and that even people with severe dementia still deserve dignity. And our challenge is to learn how to treat them in a way that respects their dignity.

Another question that came to us is one that actually I’d love to hear. The question is is there a way to differentiate between worsening dementia and the effects of polypharmacy? At the outset, I introduced myself as a geriatrician. A geriatrician is a internal medicine doctor who has done additional training and board certification in the care of elderly people. And we as geriatricians approach some of our issues differently from our colleagues in internal medicine. And one of the things that we really don’t like is pushing a lot of medications because we realize that the older people are, the more susceptible they are to side effects. And that prompts us to want to get people on as few drugs as possible.

One of my partners in my practice over the years used to say that drugs are poisons with a few good side effects. And that’s true. And I think any good physician has to respect the potential damage that many medications can give. So the question is how do we distinguish dementia getting worse from a side effect of a drug? And that admittedly is sometimes tough. But a couple of questions we can ask. One, is this a common or even a reported side effect of the drug? I’ve had people report side effects that I think had nothing to do with the medication, and the side effect had never even been reported. It doesn’t mean it couldn’t be, but it’s less likely. Secondly, most of the drugs that are used in older folks can probably safely be stopped for a short time. Some of them require the dose to be tapered and they can’t just stop it directly, but you can often get people off the drug without too much harm. And then you know whether the side effect was caused by it or not. And if you have a major problem develop, there’s no harm with starting the drug again.

And then we always want to ask, particularly with older folks, is this drug that I’m taking really necessary? Is it really helping? And I encounter that a lot with the drugs that are used for dementia. They have proven to in some patients delay the progression of the disease, but no one believes that they really make the disease better. They may just slow it down some. And of course, how do you know if a drug is slowing the progression of the disease? The answer is simply you don’t. And so my attitude has always been if there seems to be a significant side effect, the amount of benefit from these dementia drugs, it does not justify their continuance.

So, the next question that was sent in is how can believers have a biblical perspective on modern medicine? That is something which I’ve thought through quite a bit and written quite a bit on over the years. But I start with Genesis one. When God created Adam, he said to take dominion over the earth. And I view all technology, including all medical technology, as part of that mandate to take dominion. All disease, I believe, is a result of the fall. God created a world and called it good. Everything worked together well. There was life, there was health, there was righteousness and peace. These were all part of God’s original creation. And then when Adam and Eve first sinned and disobeyed God, all of that good creation began to unravel and health became disease, life became death, righteousness became evil. And it all, as I said, began to unravel. It was no longer the good creation that God had made.

But God, I think primarily through Christ, allows some of that, the results of the fall to be reversed so that sin can become righteousness, death can become life. And I think in that same paradigm, we can say that disease becomes health. And that is all part of God’s reversal of the effects of the fall. But I think it’s good to emphasize that most of the time God works he uses some human intervention. Just think through how many miracles we see in scripture where it was done with some human participation. When God wanted to open the Red Sea, He told Moses to hold out his staff. When they wanted to purify polluted water, He told Elisha to throw in the tree.

And I love the story of the feeding of the 10,000. When Jesus was confronted with 5,000 hungry men on a hillside and wanted to feed them, he could have prayed and asked God to raise their blood sugars 50 points. He could have prayed and asked God to fill their bellies with roast beef and mashed potatoes. But instead, what he did was use what a little boy had to give, which was five loaves and two fish. He broke them and fed the multitude by that miracle. And God used that little boy to accomplish and do his part in the miracle. And by the way, I suspect that the person who filled his stomach the most that day was that little boy. And I think he went home to his parents with a very full tummy, just having been thrilled by being a part of Jesus’s miracle.

And so I think God is the one that heals. And I think he uses medicine. I don’t think it’s medicine that heals. In fact, we used to have a sign in the basement of our office where I practiced for many years, which said, “God heals; the physician collects the fee.” And I think that’s [inaudible 00:18:18]. It is God who heals. And when we take medication, we often give thanks for our food when we sit to eat, one thing that I think a lot of Christians say when they give thanks for the food is, “Please bless into our body’s use.” And yet I think when we’re taking pills, we should bow our heads and say, “Lord, thank you for this penicillin,” or, “Thank you for this blood pressure drug. And please bless it to my body’s use,” because it’s God who does the work, we just are participants.

And then that brings me to the other key part in understanding the role of God in medicine. In James chapter five, he tells us when we’re sick to call for the elders of the church and pray. And prayer is an essential part of God’s healing work. And I don’t think that excludes non-elders, but we may want to start with them and recognize that there’s nothing that’s going to be truly beneficial in the medicine that we’re taking unless God is at work. And what a privilege it is to be co-laborers with him in that project of medicine.

So our last question we want to discuss today is how does someone finish their race well, with dignity and to the glory of God? That is an issue which has really intrigued me for a number of years. It is with that question in mind that I decided to do a degree at Trinity Evangelical Divinity School in bioethics so that I could come to a better synthesis of scripture with my geriatric practice. And it resulted in the first book which I published, which is called Finishing Well to the Glory of God. And that’s been just a real ongoing theme in my life. And right now I’m just finishing a fourth book, which I am calling Retirement for the Glory of God. How do we intentionally plan our retired years to be able to bring glory to our savior?

Well, thinking through the kind of basic outline of that book, Finishing Well, I start with the need to keep ourselves healthy. There’s a lot of things that we need to do in our later years to promote good health and promoting good health, hopefully promote good opportunities for service to God. And that implies get in a good diet. Sometimes I need to remind myself of that. It means to get out and get some exercise. And follow through with your medical checkups, your screening tests. And all of those things, I think, go toward helping us finish the race well. Then most of us are pretty tied to the world. We’re tied to the world’s things. We’re tied to the world’s values. And we need to look at our lives and ask, “Where is my heart? Is my heart on the things of this world? Am I valuing things of this world? Do my values reflect the values of the people around me? Or am I treasuring God and his things treasuring, treasuring his values? Am I thinking the way God thinks?” And begin to realign our values to be like Him.

The next thing, and this is tough, I talked at the outset of our time this morning about some of the difficulties that we face at the end of life. I talk about the five Ds: disease, depression, dementia, death, all so common toward the end of life. And there’s oftentimes suffering that comes at the end of life. And I think it’s critical if we’re going to end well to have a good theology of suffering. We need to be able to allow the difficulties of life not to make us question and run away from God, but to push us to depend more on him. And so part of finishing our race well is understanding God’s use of the difficulties of the end of life to make us more like himself.

Next, we need to understand technology as we discussed under our previous question and accept the many things which medical science can do to help us live longer and better lives. But, be very, very careful that we put our faith not in technology, but in God. And I’ve seen way too many strong believers over the years put their faith in medical technology. I used to do some work in the intensive care unit at one of the local hospitals, and I would round in the intensive care unit. And I would find people there who were fighting for life against almost impossible odds. And you knew they were going to die, but they were still clinging to hope. Hope not in God, in heaven, but in hope in some miraculous cure that we knew wasn’t going to come. And we need to help people use technology when it’s appropriate, but not put their faith in technology.

One phrase that I’ve used many times over the years with believers as they come to the end of life is, “Heaven’s not so bad you have to fight too hard to keep out.” And that’s some of them who we’re seeing. We’re seeing just people fighting with all the technology they can. And what are they finally accomplishing? Keep them out of heaven a little bit longer? And we just need to help people understand that it is God’s will to take us home to glory and we shouldn’t be fighting against him. And then we want to be able to rest in Jesus when the end of life comes. It’s not a fight to the finish. It’s not a failure of technology. It’s simply being able to rest in God. And I’m a great fan of hospice. And I think it’s wonderful to be able to use what hospice can give us, allowing us to be home with our loved ones and families and die peacefully and as I said, not make it a fight to the finish. Because we’re ready to go, we’re ready to see Jesus. We’re finishing that race. I fought a good fight. I’ve finished the course. And there now lays up for me, the crown of righteousness, which the Lord has secured for us.

And I realize that as I love Hebrews 12, it talks about running the race. And the at the finish line is Jesus. And we’re in the stadium there. And I see that stadium is filled with all God’s people who have gone before us. And they’re sitting in the grandstands there, saying, “Go, John, go, John, run hard, run to the end.” And then at the end of the race is Jesus standing to welcome us home. And if we can keep our goal in view, I think it makes the passage much easier.

As we close this morning, I’d just remind you that God is in control. God is loving us and God is able to honor Himself through the later days of our life. And it’s not something we need to fear, but we can look forward to the time when we are with Jesus.