Article on Dementia & Dementia Care by Dr. K. Bhanu, Director of Neurology and Neurosurgery, Dr. Mehta’s Hospitals, Chetpet.
My aunt and uncle were returning to India from New York and had to change flight at Paris Airport, France. My aunt had gone to get coffee and when she returned, she could not find her husband and waited for a while thinking he might have gone to the restroom. It soon turned into a nightmare when he could not be located at the airport and filed a missing person report. Thankfully he was found wandering in the streets of Paris, talking incoherently and police brought him back to the airport. This is a common scenario in persons with memory loss. Many elderly persons are not able to find the way back home because they have lost the ability to find the way back home.
We do have memory problems as we age, like misplacing keys, etc which we are able to retrieve later. This is normal forgetfulness. Aging produces microstructural changes in the brain resulting in some decline in brain function, but we can function independently. The interphase between normal aging and dementia is known as mild cognitive impairment (MCI), usually affecting domains of memory or executive functions. All of us age, but do not get demented.
‘Dementia’ has its origins in the Latin word dementatus, meaning ‘out of one’s mind’. Dementia is a disorder associated with changes in the cells of the brain These changes adversely affect cognitive functions along with functional independence an often-heard statement in dementia care is “he/she is no longer the father /mother I have known in my earlier days “Dementia robs the person not only his memories and personality but often his dignity as well.
There are about 10 million new cases of dementia each year worldwide, implying one new case every 3.2 seconds (WHO, 2019). There are about 5 million people with dementia in India and many more at risk of developing this condition Undoubtedly caring for someone with dementia is one of the toughest jobs and families often do it with no social support.
Dementia is a general term to describe a group of symptoms that occurs due to the death and decay of brain cells. The common symptoms are impaired memory, thinking, language, comprehension, judgement, decision making, and orientation. In addition, behavior and personality changes can occur. There is wide variation in how the disease progresses among individuals but invariably the affected person will be unable to carry out his daily activities. Progression is also based on the type of dementia.
Dementia usually affects the elderly, but can affect young people rarely. Several different diseases can cause dementia. More than one form (mixed dementia) can exist in the same person. Alzheimer’s dementia (AD) is the most common type of dementia out of the three types of dementias ie Alzheimer’s, vascular and Lewy body which may co-exist. It progresses through 3 stages from mild to moderate to severe. Starts slowly and progresses gradually with increasing forgetfulness and memory problems are often early symptoms. Can later become confused, lose their way around familiar places, have difficulties with planning and completing simple tasks, making decisions and judgment may be impaired. In late stages, patients may have global impairments affecting all cognitive and intellectual functions.
The cause/aetiology of AD is multifactorial, with an interplay of environmental and physical factors. Genetic factors have a role in early-onset AD. Brain changes occur in AD, includes gross brain atrophy, hippocampal atrophy, widened sulci, and increased ventricular size. Microscopic changes include amyloid plaques and neurofibrillary tangles.
Another dementias are vascular dementia caused by an impairment in blood flow to the brain. Repeated strokes or strokes in certain strategic locations can present as dementia. Severe depression can also be associated with impairments in memory, concentration, and an overall reduction in intellectual abilities, and since it mimics dementia called ‘pseudodementia’ Elderly patients admitted to hospital for physical problems are at a high risk of delirium especially in the presence of dementia
The person with memory impairment needs to be evaluated. Blood tests are required which help to rule out physical disorders that can cause this such as thyroid abnormalities, anemia, vitamin deficiencies, metabolic and electrolyte abnormalities, liver and kidney problems. Additional tests may be done based on the clinical situation like VDRL, HIV testing, Chest X-ray, ECG, EEG, Lumbar Puncture, etc. Sometimes strokes, tumors, infections of the brain etc., may present with memory and difficulties with carrying out the normal day to day activities, and to evaluate this a brain imaging (CT or MRI scan) is usually done to assess the extent of any structural changes or the cause associated with dementia.
Current intervention practices for dementia are pharmacological and non-pharmacological. Pharmacological therapy includes drugs – cholinesterase inhibitors (ChEI) drugs-rivastigmine, drug of choice for mild to moderate AD. Other medicines such as Donepezil and Galantamine are also used in different countries. The difference ineffectiveness of these drugs lies only in the tolerability of the medication. A combination of drugs are used in moderate stages of AD showed favorable responses on Global Clinical Impression and behavior assessment scales suggesting benefits in some individuals.
Non-pharmacological interventions can help in the early stages. These include eating a nutritious diet of fruits/nuts, reducing the use of refined sugar, avoiding alcohol /smoking, and staying hydrated. Providing a stimulating environment and social interactions with friends and relatives can be helpful.
Family conflicts may arise due to psychosocial issues that arise while caring for a demented person. Can have anger outbursts, inappropriate sexual and high-risk behaviors which can lead to legal battles especially if finances are involved and need management. The disease can progress and hence it is important for the doctor to discuss with the individual and family regarding long-term care. This will include the living will which can tell us about the ideas of how they would be like to be treated/cared for if a situation arises when they cannot express themselves or handle day-to-day activities including finances and other legal issues.
This is a very important matter and seldom discussed. This has to happen when the doctor and patient and family are able to sit and have a conversation in a detailed manner to make life more meaningful for the sufferer and family. Caring for a spouse or parent with dementia can take a mental toll and produce depression and often called “the invisible second patients “ and can take the help of siblings/friends/volunteers etc. It is very important to know that regular physical exercises (such as walking/cycling ), maintaining a healthy weight, avoiding alcohol and smoking reduces the risk of dementia. Stay mentally alert by learning new skills. Connecting and interacting with friends and doing mentally rewarding tasks stimulates the brain. These activities may help the brain to rewire and delay dementia FAMILY AND SOCIAL SUPPORT ARE VERY ESSENTIAL IN DEMENTIA CARE.