Expert: Mary Gordon - 12/4/2008

Question
My mother has bravely looked after my father at home in the UK for 10 years after he was diagnosed with Alzheimer's. He has been totally incontinent for the last 4 years, not been able to talk for the last 8 years and now on very soft food.  He seems very calm but has over the last 2 months developed a clenched fist.  He seems to be in pain with it, probably because his fingernails are digging into his palm. My mother finds it very difficult to cut his nails and is considering having a nerve cut in his hands to open it out.  Do you consider this the best action to take?    Many thanks,  Georgia

Answer
Hi Georgia, I'm sorry it took me so long to get back to you.

What has the doctor advised? They make all kinds of hand splints and wraps just for this purpose, since the clenched hand makes it very difficult to keep the skin clean and dry. The nails can also cut into the skin, and make them susceptible to infection.

Its called contracture.

Here are some samples of the products out there to assist with this issue- they don't stop the contracture, but they might make it less painful, or keep his nails from cutting his palm.

http://www.pelicanmanufacturing.com.au/cgi-bin/store/commerce.cgi?pid=126&ppi=PI...

http://www.abledata.com/abledata.cfm?pageid=19327&ksectionid=19327&top=11845

http://www.regalmedical.com/products/whfo/home.html

One approach that has helped many - believe it or not - is to use botox shots, which can relax the muscles and reduce the pain. Might be worth asking about, or giving a try if this might be a possible idea.

I don't know what she has tried so far, or what her discussions with the doctor may have been. Were there other options proposed? Do you know what it is from? Is it a consequence of stroke (i.e., its not a routine part of Alzheimer's and you describe it as one sided). After a stroke, many people develop contracture of the muscles in their affected wrist and hand which leads to a permanently clenched, painful hand. Or perhaps does he have Dupuytren’s?

This type of contracture is from the thickening and shortening of the connective tissue (fascia) in the palm of the hand. It is a common condition that is benign (non cancerous), painless, but gradually progressive, which means that it becomes worse over a period of time. Dupuytren’s contracture occurs most often in later life and affects around one in six men over 65 in the UK. This makes it relatively common. This one can be treated by surgery called palmar fasciectomy, which involves cutting out or dividing the thickened tissue. There is also a less invasive surgery called needle fasciectomy.

If it were my father, I'd find out exactly what the cause was before any decision about severing nerves is made.  Nerves being severed will cause permanent numbness. Unless it is Dupeytren's and can be readily fixed with surgery in terms of relaxing the hand so he's comfortable, I think I'd be inclined to to try the various types of splints first to keep his fingernails from hurting his palms, perhaps along with asking about something to relax the muscles, such as the botox.

Either way, I'd tell the doctor NOT to put him under a general anesthetic for any surgery, should that be the final decision, but to find a way to do it under sedation and a local. General anesthesia is really not good for people with AD - they can really go down hill from it, and often do not ever recover the ground they have lost.

Hope this helps.

Mary Gordon
Toronto