Melvin G Hector

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• Hector, M. (2023).

  Is Dementia a Disease?

  . Caring for the Ages, Volume 24, Issue 3, 11. doi:10.1016/j.carage.2023.03.016
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  At the end of clinic day today I had been invited to speak to a church group via Zoom about the topic of dementia. I thought it might be fun to talk with people about dementia, as I do with my patients, without the need for a slideshow or references. The format was set up so that I would talk a little about dementia first, and then I would answer any questions. With so much to cover, I decided to focus on what aspects of dementia I wish we all understood better. I started with the observation that we were talking about an issue that some researchers in the field view as an inevitable consequence of aging. Their contention is that if every one of us lived long enough we would all eventually develop dementia. It is not dissimilar to the notion that our joints wear out over time and would show deterioration after 70, 80, 90, or more years of use. It isn’t a shock when our joints show that expected decline, so why are we shocked if and when our brains show signs of wear? There are, of course, stressors, tragedies, and losses that come with this process. To watch a personality or a sense of humor or an identity wear away is not the same thing as the loss of that meniscus, cartilage, tendon, or bone and the physical capability. Yet both processes could be understood as signs of attrition among living beings. As a geriatrician, I’m frankly at a bit of a loss as to how dementia became a “disease.” I am familiar with the medical model’s approach to problems: identify an anomaly and find a cure. Dementia, when identified as an enemy, becomes a concept worthy of defeat at any cost, no matter how much energy, resources, funding, and effort are required. We have literally spent billions if not trillions of dollars in the spirit of this model. We have diagnostic efforts that are becoming more and more exact at predicting the advent or advancement of this part of our gray matter so that — what? So that we can recognize it and offer treatments that are modestly effectual, do not change the course of the process, but justify our involvement and manifest our concern? Truthfully, they mostly rule out other possible conditions, which may be a worthy goal. And, all the while, the media are fanning the flames we’ve ignited of this deemed catastrophe, reporting that yet another thing to fear is widely dispersed while trivial and not-so-trivial attempts at treatment are advanced. The fact is that these serve mostly to benefit those who are marketing them to patients or families desperate for treatment. What if, instead, we taught everyone to ward off the onset of this condition in ways we know work? There are excellent data showing that maintaining a healthy weight, exercising, keeping your mind busy, watching your blood sugars and blood pressure, moderating your alcohol intake, and stopping smoking might all have salutary effects in delaying progression toward dementia. Some patients may require medicines to help accomplish some of these measures, but we have no clinically effective medication — yet — that will actually make a significant impact on halting or even slowing down this attrition of our minds. It all comes down to education, awareness, understanding, the willingness and integrity to teach this lesson and to be taught, and to actually do what has been shown to work. In her book Dementia, Together — How to Communicate to Connect (Puddle Dancer Press, 2020), Pati Bielak-Smith offers four things that we might need to start with. There is the diagnosis itself, with a truly unnecessary epidemic of fear built upon the possible consequences of having dementia. There is the person affected by that condition as it progresses in their lives. There are the caregivers who valiantly deal with these issues in the context of providing the best they can for the ones they love. And finally, there is the need to patiently embrace the conditioning, communication, and understanding that must happen between that person and his or her caregivers. These are tasks that are truly worthy of attention, funding, interest, instruction, leadership, and talent. After I gave my talk, the questions from the audience were predictably aligned with everything they’d heard up to now. Do I need to be tested? Where? Do I have dementia? What resources are there locally? What about all these medications advertised for memory on television? A discussion ensued, limited by the 60 minutes of time we shared. What I chose not to emphasize was the recent attention drawn to the potentially fabricated research on amyloid beta plaques in brain tissues as a cause of Alzheimer’s disease (Science 2022;377:358–363). This hypothesis, promulgated by major journals, led to years and years of effort and expense to (unsuccessfully) duplicate and confirm the results — all without challenging the questionable data of that first influential study. I also did not dwell on the medications developed based on this hypothesis, which are obscenely expensive. Yes, their results show tangible regression of some of the structures of what we recognize as microscopic evidence of dementia — yet without any significant effect on the patient that might justify the cost or the potential side effects. I regret our unquestioning faith in the medical model as a solution for a condition that is not a disease. We could instead spend more time, money, effort, and research on how to develop the care that patients with the condition called dementia will need to sustain their valued existence in a way that is consistent with their hopes, desires, dreams, and needs. We need to have the humility to recognize, teach, learn, and fund such care so that it will indeed be there if and when we ourselves at that doorstep. At the end of my talk, it occurred to me how vulnerable I felt in expressing such concerns and doubts about a profession I love and a methodology I respect. By voicing our doubts, we call into question so much of what we do today and how we approach this and other significant and important problems. I suspect medicine can handle the query. But are we, as professionals, willing to change our perspective from viewing this condition as a disease? And are we able to accept that our colleagues in the therapies, social work, nursing, and public health fields might actually do a better job for our patients with this particular condition, that they may have more to offer our patients and their families? Dr. Hector is a certified medical director and is board certified in family practice, with a CAQ in geriatrics. He works as a clinical associate professor in the Division of Geriatrics, Palliative Care, and General Internal Medicine at the University of Arizona. His views are his own and do not represent those of the Society nor any other entity.
• Hector, M. (2022).

  Brilliant Agent Orange.

  . Journal of the American Geriatrics Society. doi:10.1111/jgs.17593
• Hector, M. (2022).

  The Importance of Vitamin D in Long-Term Care Residents

  . Caring for the ages. doi:10.1016/j.carage.2022.01.016
• Hector, M. (2020).

  Poems

  . Caring for the ages. doi:10.1016/j.carage.2020.04.006
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  Every day, there are so many opportunities to witness the joys, frailties, regrets, hopes, fears, acts of kindness or vengeance, shyness, resilience, and love that occur in the life of staff, patients and peers in our busy venues. There is material for a lifetime. To pause and recognize what was just witnessed, write that raw information down, categorize it within our library of thoughts and feelings, see where it fits, and share it with others so engaged, if it helps them with their perspective, enthusiasm. and appreciation, is its own joy. It keeps things real, keeps us engaged, and is a part of why we want to go to work every day; it is the real story of our lives, the minutiae that, though writ small, consume our busy days. And that, in turn, lets us explain to others our passion for what we do. Poetry, plays, short stories, screenplays, novels, music, art, it matters little the medium, just start, make it yours, and see where you end up. Then, do it again. I’m in someone else’s chairI sleep in someone else’s bedI’ve got someone else’s thoughtsUsing someone else’s head.I feel someone else’s handsFeeding someone near me’s faceI’ve got someone else’s swallowLeaving none for me to taste.I’ve got someone else’s scheduleDriving me from place to placeI’ve got someone else’s lifeAnd it should be a disgraceBut I can’t find a betterLife or memory or placeThan the one I find I’m livingHere in someone else’s space.When I look into the mirrorI see someone else’s faceNot a bad one, not a sad oneJust a change through time and space.Every person here is happyThat I’m whom they think they seeSo there is no cause for panicIf everyone believes I’m me.But it is very scaryA thought I try hard not to fosterBut it cannot be too longBefore they find out this imposter.Then there’ll have to be a reckoningAnd I’m afraid that they’ll demandSomething I don’t have to offerWhich is simply who I am.I’m in someone else’s chairI sleep in someone else’s bedI’ve got someone else’s thoughtsFlying ‘round inside his headBut I’ll tell you what I do know:‘Some one’ part of me is dead. It was a painstakingly slow attempt at action.She refused to let the head of her bed be raised.Her wisps of hair were in thin disarray.As he placed the end of the strawTo her parched lips, I thoughtThey’re not going to make it.Sure enough, even when she was ableTo make a seal with her lipsAnd try to draw the contents into her mouthAssisted as it was by capillary actionCarbonation, Brownian motionThe gravitational pull of the tidesHis body English and tipping the canAs much towards her as he daredThis Orange Crush, her favoriteWas not going to climb that strawOne last time. It was too tired.Another approach was needed.He placed his finger tipOver the end of the strawTook the straw from the canAnd then let the column of cold orange sodaDrizzle into her mouthMuch like they had done as kids.She seemed to like that better anyway.There was the occasional excess;A thin trickle of a citrus rivulet slowlyFound its way down her neck to her gown.I am quite sure that she giggled.Yes, this was loving, to the very endA fitting finale for the beloved Orange Crush. Sometimes you can hear Death coming.The muffled whump, whump-whump, whumpOf distant mortars can be pointed anywhereBut when rounds scream in on your positionAnd you dive for any low spot in the paddyAnd endure closer and closer ear-splitting blasts,With horrific cries from voices you recognizeBut are not your own, you realize what you heard.Death walks through with random blatant disregardAnd you become aware, through no act of your ownThat you must have survived, to be witness toWhat sucking chest-wounds actually look likeAnd how much young extremities can bleedBefore they’re whisked away, still alive, so far.Fifty years later, I am reminded again, thatSometimes? You can hear Death comingWith random blatant disregard.Be smart. Lie low. Be aware.We’ll get through this. Dr. Hector provides care for older adults and trains residents and fellows in geriatrics for Banner Health. He works in three post-acute care facilities as a Team Health provider.
• Choi, M., & Hector, M. (2012).

  Effectiveness of Intervention Programs In Preventing Falls: A Systematic Review of Recent 10 Years and Meta-Analysis

  . Journal of the American Medical Directors Association. doi:10.1016/j.jamda.2011.04.022
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  To examine the reported effectiveness of fall-prevention programs for older adults by reviewing randomized controlled trials from 2000 to 2009.Systematic review and meta-analysis of randomized controlled trials.A systematic literature search of articles was conducted using 5 electronic databases (Medline, PubMed, PsycINFO, CINAHL, and RefWorks), including articles describing interventions designed to prevent falls, in English with full text availability, from 2000 through 2009.Of a potential 227 studies, we identified 17 randomized controlled trials with a duration of intervention of at least 5 months of follow-up. Inclusion and exclusion criteria were used to assess the methodological qualities of the studies. We excluded unidentified study design, quasi-experimental studies, and/or studies that were nonspecific regarding inclusion criteria.Primary outcome measures were number of falls and fall rate. Methodological quality assessment included internal and external validity, reporting, and power. Data were extracted independently by 2 investigators and analyzed using a random-effects model. We analyzed the effectiveness of these fall intervention programs using their risk ratios (RR) in 2 single-intervention versus 15 multifactorial intervention trials, 3 nursing homes versus 14 community randomized controlled trials, and 8 Model 1 (initial intervention with subsequent follow up) versus 9 Model II (ongoing intervention throughout the follow-up) studies.The combined RR for the number of falls among 17 studies was 0.855 (z = -2.168; p = .030; 95% CI = 0.742-0.985; Q = 196.204, df = 16, P = .000, I(2) = 91.845), demonstrating that fall-prevention programs across the studies were effective by reducing fall rates by 14%, but with substantial heterogeneity. Subgroup analysis indicated that there was a significant fall reduction of 14% in multifactorial intervention (RR = 0.856, z = -2.039, P = .041) with no variation between multifactorial and single-intervention groups (Q = 0.002, P = .961), 55% in the nursing home setting (RR = 0.453, z = -9.366, P = .000) with significant variation between nursing home and community groups (Q = 62.788, P = .000), and no significant effect was gained by dividing studies into either in Model I or II. Sensitivity analysis found homogeneity (Q = 18.582, df = 12, P = .099, I(2) = 35.423) across studies with a 9% overall fall reduction (RR = 0.906, 95% CI = 0.853-0.963, z = -3.179, P = .001), including a fall-reduction rate of 10% in multifactorial intervention (RR = 0.904, z = -3.036, P = .002), 9% in community (RR = 0.909, z = -3.179, P = .001), and 12% in Model I (RR = 0.876, z = -3.534, P = .000) with no variations among all the groups. Meta regression suggested that the model fit explained 68.6% of the relevant variance.The meta-sensitivity analysis indicates that randomized controlled trials of fall-prevention programs conducted within the past 10 years (2000-2009) are effective in overall reduction of fall rates of 9% with a reduction of fall rates of 10% in multifactorial interventions, 9% in community settings, and 12% in Model I interventions (initial intervention efforts and then subsequent follow-up).
• Choi, M., & Hector, M. (2011).

  Effectiveness of Intervention Programs in Preventing Falls for Older Adults in Long Term Care Facilities

  . Journal of the American Medical Directors Association. doi:10.1016/j.jamda.2010.12.038
• Hector, M. (2004).

  Saving the Best Rights for Last: The Nursing Home in Your Future

  . Journal of the American Medical Directors Association. doi:10.1097/01.jam.0000104804.44392.78
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  Gummy bears, skin tears, bedpans, deadpans, and dustpans.
• Hector, M. (1992).

  Treatment of accidental hypothermia.

  . American Family Physician.
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  Hypothermia is an underreported cause of death in the United States. The clinical presentation of hypothermia may include neurologic, cardiovascular and metabolic abnormalities. In severely hypothermic patients, evaluation may reveal no signs of life until the patient is rewarmed. Treatment is directed at restoring normal body temperature and attending to fluid resuscitation, electrolyte disorders, cardiac arrhythmias and associated disease states or conditions. Groups at particular risk for hypothermia include outdoor workers, the homeless, trauma victims and the very young or very old. Also at risk are persons with preexisting serious illnesses and those who are taking medications or abusing drugs. Cardiac arrest, hypotension, unresponsiveness and severe hyperkalemia portend a poorer prognosis.
• Burton, J., & Hector, M. (1989).

  In Reply

  . Journal of the American Geriatrics Society. doi:10.1111/j.1532-5415.1989.tb02253.x
• Burton, J., & Hector, M. (1988).

  What are the Psychiatric Manifestations of Vitamin B₁₂Deficiency?

  . Journal of the American Geriatrics Society. doi:10.1111/j.1532-5415.1988.tb04397.x
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  Psychiatric symptoms attributable to vitamin B12 deficiency have been described for decades. The earlier reports are for the most part in accord with more recent ones, despite being diagnostically less specific in psychiatric and hematologic terms. These symptoms seem to fall into several clinically separate categories: slow cerebration; confusion; memory changes; delirium, with or without hallucinations and/or delusions; depression; acute psychotic states; and (more rarely) reversible manic and schizophreniform states. While there still remain abundant hematologic, psychiatric, neurologic, or nutritional reasons for obtaining a serum vitamin B12 level, its use in the investigation of the etiology of a patient's dementia seems unjustified. However, acute or subacute changes in a demented patient's mental status, specifically a clouding of their consciousness, may make such testing advisable as part of the complete workup of their delirium regardless of a normal hematologic picture.