Recently a 75-year-old businessman consulted me over a gradual deterioration of his memory and inability to do simple calculations, and lack of interest in daily life. His family who accompanied him spoke of changes in behaviour and attitudes to family and friends. He seemed to have lost interest in business and work. There was also unusual behaviour such as leaving the house early in the morning for no apparent reason as well as getting frequently lost in an environment he had lived in for many years.
A normally mild-mannered person, the family also noticed he was becoming aggressive and argumentative.
The visit to me was prompted by a recent episode where he had gone to the boutique close by, and interfered in a domestic squabble, causing embarrassment to his family. This is the typical scenario of a dementia patient and most of us may know of someone who has some of these traits. Although it is not a common condition understanding dementia and being able to manage it appropriately will help the patient as well as the carers.
What is Dementia?
Dementia is a group of illnesses in which there is a gradual decline in memory with involvement of one or more other factors affecting cognitive domains. The patient’s functioning gradually deteriorates to a point where he is unable to attend to his own day-to-day routine. He may forget to brush his teeth or wash and later become totally dependent on others.
The common behavioural problems include aggression, lack of inhibition, wandering about and not attending to basic hygiene needs.
These problems become more difficult to manage and often caregivers may be at the receiving end.
The sufferers can hit out, pinch and bite the caregivers, and worse may not even recognize loved ones. This is the time that the sufferer may have to go to a nursing home for future care.
This scenario is common in the West but less so in countries such as Sri Lanka where the family tries to look after the patient to the best of their abilities due to cultural reasons, lack of affordable nursing homes or obvious poverty.
Although this is admirable, the impact of these difficult patients on the family can be significant. Moreover the home may not be the best environment for the patient. Even if the patient is not admitted to a hursing home long term it may offer the services of respite care.
What are the main types
of dementia?
- Alzheimer’s disease
- Vascular dementia
- Dementia with Lewy bodies
- Secondary dementias (As the name suggests these are due to other illnesses, e.g. thyroxine deficiency, Vitamin B12 deficiency, tumours of the brain or more commonly, subdural haemorrhages particularly in the elderly, following falls etc)
Alzheimer’s disease is the commonest. There is no causative factor so far found, but nearly 15 million people worldwide are affected by it.
The symptoms are:
- language disturbances (aphasia)
- Impaired ability to carry out functions even if there is no weakness in the limbs (apraxia)
- Failure to recognize objects even though there are no sensory problems (agnosia)
- Difficulties with planning and organizational problems (executive functions)
- Decline from previous level of general functioning but which should not be due to any other illness.
Vascular dementia: The second commonest dementia this usually starts abruptly and gradually deteriorates in step-wise fashion. Important risk factors include previous history of minor or full blown strokes, hypertension (high blood pressure), irregular heartbeat, smoking, Diabetes, hypercholesterolemia, and a family history of previous or ongoing vascular disease.
Mixed dementias: Here you get the features of both Alzheimer’s disease and vascular dementias. It is difficult to separate them. Postmortem brain biopsy studies would help.
Dementia with Lewy Bodies: This is characterized by Lilliputian visual hallucinations and recurrent falls in addition to memory loss and other features of dementia. It is important to realize that these dementias are sensitive to anti –psychotic drugs that should be used carefully or if possible not at all. Variability of dementia features at various times is not uncommon.
The other type of dementia which occurs in association with Parkinson’s disease is not the same as Dementia with Lewy Bodies. A geriatric physician or psychiatrist experienced in elderly care may be able to differentiate them and treat accordingly.
Secondary dementias: These are normally due to deficiencies of various factors, hormones, vitamins or abnormalities of certain minerals, or various tumours of the brain. Replacement of those substances which are lacking can make a great improvement in the condition. In case of normal pressure hydrocephalus, relatively a common condition (where we get large sized brain ventricles with normal CSF pressure), insertion of a shunt, may show excellent results.
How is dementia diagnosed?
As in any other illness, it is very important to get a reliable account of what is happening. The most reliable information is given by the patient and also the closest relative - spouse or child, close associate or carer.
History
It is important to find out when the patient started to behave unusually. Was the change gradual or quite sudden? Was there loss of memory? Changes in behaviour? Did the patient have any falls, arguments, or any physical fights? Is the patient being treated for any other diseases? Has he been treated for depression? What drugs is he using? What kind of education has he/she had, primary, secondary or university? These are all important questions and will aid diagnosis immensely.
Clinical examination
This is mandatory especially focusing on neurological status.
Psychiatric or psychological examination
- Mini Mental State Examination test (MMSE)
- Clock drawing test and marking a specified time
Mini Mental State Examination test can differentiate the illness roughly to mild, moderate or severe verities on the score of the test. The test is scored out of 30 and usually takes about 7 minutes to perform.
Mild dementia 22-----26
Moderate dementia 10-----21
Severe dementia 0-----09
The clock drawing test with a specific time, usually takes about 5 minutes, and has a specificity and validity over 80%.
Investigations
In addition to routine laboratory tests, it is important to exclude hypothyroidism, Vitamin B 12 deficiency, low serum folate levels and also tertiary syphilis, even though it is rare nowadays. Metastatic cancer and high serum calcium are also important in the investigations of dementia.
CT and MRI scans are a must for the diagnosis of dementia.
In certain situations early detection of dementia is done through memory clinics, conducted by a multidisciplinary team headed by a geriatric psychiatrist as the team leader.
Management of dementia:
In the past, management was basically directed towards symptomatic treatment. This has changed. There are medications that can be used for treatment and management. However precise diagnosis is important.
Two types of
management
- Environment modification or non pharmacological treatment
In environmental modification all necessary steps have to be taken for reality orientation which is essential for dementia management. Simple steps such as depiction of the day of the week, day, month and the year should be written out so that the patient can see it. This is called reality orientation. Only a few people, one or two should help the patient in daily needs.
This is vital in case of a hospital environment. This may help to alleviate difficult behavioral problems like aggression and non-compliance with instructions.
It is important that patients take a healthy nutritious diet. The food must be tasty and not monotonous.
The help of a qualified good dietician is beneficial.
Patients should have some exercise and activity. Many seem to enjoy old songs, and playing old music and simple games. Most of them have a good recollection of their young days and talking and reliving those memories should be encouraged.
- Pharmacological treatment
There are three (3) choline esterase inhibitors which are used in mild to moderate Alzheimer’s disease. It is known that Alzheimer’s disease is characterized by the cholinergic deficit.
The three main drugs licensed in U.K. are Donazapil, Galantamine and Rivastigmine which are prescribed for patients who have either mild or moderate Alzheimer’s disease
Dementia is a disease of an aging population and we must be aware of its existence so appropriate help may be provided for the patients and carers.
An early diagnosis will enable the understanding of the condition and better care for those affected.
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