Understanding Dementia

Dementia is an umbrella term for all the progressive neuro-degenerative conditions which affect the brain and are severe enough to interfere with normal functioning. It generally affects the elderly population above the age of 60 but is not a normal process of aging. Unfortunately there is no cure for dementia, but certain conditions are reversible.

Alzheimer’s disease is one of the most common form of dementia, amounting to 60-70% of the cases. Other conditions include vascular dementia, Lewy body dementia, mixed dementia, Creutzfeldt-Jakob disease, Parkinson’s disease dementia and Huntington’s disease.

According to a World Health Organization (WHO) report, at present there are more than 40 million people suffering from dementia globally. This number will increase to an estimated 75.6 million in 2030, and 135.5 million in 2050. Much of the increase is expected to be in developing countries.

The early waring signs of Dementia are:

1. Memory Loss that disrupts daily life
2. Challenges in planning and problem solving
3. Difficulty performing familiar tasks
4. Confusion with time and place
5. Trouble understanding visual images and spatial relationships
6. Problems with words in speaking or writing
7. Misplacing things and losing ability to find the way back
8. Decreased or poor judegement
9. Withdrawal from work and social activity
10. Changes in mood and personality

1. Neurological diseases including Alzheimer's disease, Parkinson's disease, Huntington's disease, and some types of multiple sclerosis.

2. Vascular disorders. These are disorders that affect the blood circulation in your brain, eg. Stroke

3. Traumatic brain injuries caused by car accidents, falls, concussions, etc.

4. Infections of the central nervous system. These include meningitis, HIV, and Creutzfeldt-Jakob disease.

5. Long-time alcohol or drug use

1. Alzheimer’s Disease: This is the most common form of dementia. Alzheimer’s disease accounts for an estimated 60-80% of cases. It is a neurological disorder in which the death of brain cells causes memory loss and cognitive decline. The disease starts mild and gets progressively worse

2. Creutzfeldt-Jakob Disease: Also called mad-cow disease, Creutzfeldt-Jakob disease occurs in cattle, and has been transmitted to people under certain circumstances. It is a rapidly fatal disorder that impairs memory and coordination, and causes behavior changes.

3. Dementia with Lewy bodies: It is the second most common type of progressive dementia after Alzheimer’s disease. The condition causes a progressive decline in mental abilities. In Lewy body dementia, protein deposits, called Lewy bodies, develop in nerve cells in regions of your brain involved in thinking, memory and movement (motor control).

4. Frontotemporal Dementia: Frontotemporal dementia (FTD) affects the brain in frontal and temporal lobes, which control planning and judgment; emotions, speaking and understanding speech; and certain types of movement.
FTD includes a range of specific disorders with different core symptoms. But there’s significant symptom overlap, especially as these disorders progress. The age of onset is 50‘s or early 60’s. It’s also known as Pick’s Disease.

5. Huntington’s Disease: Huntington’s disease is a progressive brain disorder caused by a single defective gene on chromosome 4 — one of the 23 human chromosomes that carry a person’s entire genetic code. It is a genetic disorder and leads to dementia. Symptoms of Huntington’s disease usually develop between ages 30 and 50, but they can appear as early as age 2 or as late as 80.

6. Mixed Dementia: in mixed dementia, abnormalities linked to more than one type of dementia occur simultaneously in the brain.

7. Vascular Dementia: Vascular dementia is the second most common cause of dementia. The brain is damaged either due to repeated small strokes causing lack of blood supply (ischemic) or small bleeds (hemorrhagic). The arteries in the brain can get damaged due to hypertension, diabetes and cardiac problems. Vascular dementia also affects memory, planning, motor moments and thinking like Alzheimer’s, however, the progression here is stepwise.

8. Wernicke-Korsakoff Syndrome: It is a chronic memory disorder caused by severe deficiency of thiamine (vitamin B-1). The most common cause is alcohol misuse. It leads to memory issues and loss of social skills. This condition is reversible and can be treated.

Early Signs of Dementia
Dementia develops gradually, the early signs may be very subtle and vague, and not immediately obvious. Early symptoms also depend on the type of dementia and vary a great deal from person to person.

The checklist of common symptoms/warning signs include:
< Memory loss that affects day-to-day function
< Difficulty performing familiar tasks
< Disorientation to time and place
< Problems with language
< Problems with abstract thinking
< Poor or decreased judgement
< Problems with spatial skills
< Problems misplacing things
< Changes in mood, personality or behaviour
< A loss of initiative

Conditions That Have Similar Symptoms to Dementia:
Strokes, depression, alcoholism, infections, hormone disorders, nutritional deficiencies, delirium and brain tumors can all cause dementia-like symptoms. Many of these conditions can be treated.

Parts of Assessment:
There is no definitive diagnosis for dementia; diagnosis is made by a process of elimination of alternatives. The process involves
Medical history – past and current medical problems, family medical history, any medications being taken, and the problems with memory, thinking or behaviour that are causing concern
Physical examination – tests of the senses and movement function, as well as heart and lung function, to help rule out other conditions
Laboratory tests – a variety of blood and urine tests to identify any possible illness which could be responsible for the symptoms
Neuropsychological or cognitive testing – a variety of tests are used to assess thinking abilities including memory, language, attention and problem solving.
Brain imaging – there are certain scans that look at the structure of the brain and are used to rule out brain tumours or blood clots in the brain as the reason for symptoms, and to detect patterns of brain tissue loss that can differentiate between different types of dementia.
Psychiatric assessment – to identify treatable disorders such as depression, and to manage any psychiatric symptoms such as anxiety or delusions which may occur alongside dementia.

A. Pharmacological Dementia Management

1. Drugs Treating Cognitive Symptoms
Cholinesterase Inhibitors: Cholinesterase inhibitors are drugs which can lessen the cognitive symptoms of Alzheimer’s disease for some people. They may improve memory and thinking for a time. They work by increasing the levels of a brain chemical that is important for memory called acetylcholine. Three cholinesterase inhibitors (donepezil, galantamine and rivastigmine) are available for use by people with a diagnosis of Alzheimer’s disease.
Memantine: Memantine (meh-MAN-teen) is a different drug that works on a brain chemical called glutamate that is present in high levels when someone has Alzheimer’s disease. This drug can help improve thinking and daily functions for a time. Memantine is currently available for use by people with moderately severe Alzheimer’s disease.

2. Treating the Accompanying Symptoms of Dementia
People with dementia often experience behavioural and psychological symptoms which can be very distressing. These may include depression, anxiety, sleeplessness, hallucinations, ideas of persecution, agitation and aggression. These symptoms may respond to reassurance, a change in the environment or removal of the source of any distress such as pain. It is important to determine the causes or triggers of behavioural disturbances and deal with these. Medication should be used as a last resort, but is sometimes necessary.
Antipsychotics: Antipsychotics are drugs used to treat severe psychotic symptoms including delusions or hallucinations. In dementia, they may also be used to treat agitation or aggression. The newer antipsychotics such as risperidone and olanzapine have fewer side effects and are more commonly used. Antipsychotics will not always be helpful, and may be associated with an increased risk of stroke. If an antipsychotic drug is used, it is important to regularly and carefully monitor the person.
Antidepressants: Symptoms of depression are extremely common in people with dementia. Significant depression should be treated as it can make cognitive problems worse and diminish the person’s quality of life. Depression can usually be effectively treated with antidepressant drugs, but care must be taken to ensure that this is done with a minimum of side effects.
Anxolytics: Anxiety, panic attacks and unreasonable fearfulness can be distressing for a person with dementia, their family and carers. Mild symptoms are often helped by reassurance, adjustments to the environment or an improved daily routine. More severe and persistent anxiety is often related to underlying depression and will usually improve with antidepressants. Antipsychotics and another group of drugs called benzodiazapines are sometimes used to treat anxiety, but both should usually be avoided as a treatment for anxiety in people with dementia.
Drugs for treating sleep disturbance: Persistent waking at night and night time wandering can cause a lot of difficulties. Some drugs commonly prescribed for dementia can cause sedation during the day, leading to an inability to sleep at night. Increased stimulation during the day can reduce the need for sleep inducing medications at night. Medication to treat sleep disturbance should be a last resort, as people may become dependent on these and withdrawal of the medication may be followed by rebound sleeplessness and anxiety.
Points to Remember
< All drugs can have side effects, some of which may make the person’s symptoms worse
< Always ask the doctor why the drug is being prescribed and what side effects might occur
< A drug which is useful may not continue to be effective indefinitely because of the progressive changes to the brain caused by dementia
< Do not expect immediate results. Benefits may take several weeks to appear particularly with antidepressants. Discuss this with the doctor.
< It is important that treatment is reviewed regularly
< Keep a record of all medications, including alternative medications and vitamin supplements. Take this record to all medical appointments.
< Many people with dementia take a number of medications for different symptoms. It is important to discuss with the doctor any impact that medications may have on each other.

B. Psychosocial Therapies
Most of the research on intervention for dementia has investigated strategies for minimizing the psychiatric and behavioral symptoms. The symptoms include agitation, withdrawal from social activities, depression and psychosis which in turn affects the quality of life in patients with dementia. It is widely accepted that non pharmacological interventions have the potential to improve the outcomes, include behaviors, cognition and functional abilities. An increasing number of non-pharmacological therapies are now available for people with dementia. It should be noted that there are several areas of overlap between these therapies and, in fact, each approach is rarely used in isolation (Ballard et al, 2001).
Behaviour therapy: The efficacy of behavioural therapy has been demonstrated in the context of dementia in only a small number of studies (Burgio & Fisher, 2000). For example, there is evidence of successful reductions in wandering, incontinence and other forms of stereotypical behaviours (Woods, 1999). Meares & Draper (1999) presented case studies testifying to the efficacy of behavioural therapy, but they noted that the behaviours had diverse causes and maintaining factors, and advised that behavioural interventions must be tailored to individual cases.
Emotion Oriented Approach: The approach consists of validation, Snoezelen and reminiscence. Validation is a way of communicating, developed as an approach for persons suffering from dementia, in which recognition and validation of emotions from an empathic attitude is central. The basis of validation is the assumption that all behaviours have a meaning. Validation was developed by Naomi Feil (1967, 1984, 1989, and 1992). The method focuses on the emotional content, recognize and confirm emotions and restore persons self esteem. According to Feil, validation results in a reduction in negative affect (crying, punching, hitting) and an increase in positive affect (laughing, talking, helping others). The intervention studies that examined a broader group of dementing elderly persons show that participation in a validation group may result in an improvement in ADL-functions and an increase in verbal and non- verbal expression during group meetings (Fritz, 1986; Peoples, 1982; Babins et al., 1988).
Snoezelen is an individually oriented activity during which various sensory perceptions and experiences of the demented elderly are stimulated. This generally takes place in a special room, using light, sound, smells and tangible materials (Baker et al., 1997). Many studies (Holtkamp et al,1997; Kragt et al,1997;Moffat et al,1993; Baker et al,1997) found that Snoezelen had positive effects. During the Snoezelen sessions the people were happier and expressed interest. At the same time feelings of anxiety and sorrow decreased.
The purpose of reminiscence is to improve intrapersonal and interpersonal functioning by means of reliving, structuring, integrating and exchanging memories (Bremers and Engel, 1989, in DroÈ es, 1991, p. 118). Several aids can be used, including: photographs, songs, scrapbooks and old objects. Research regarding the effect of reminiscence in elderly people with dementia is still in the early stages (DroÈ es, 1991; Gagnon, 1996; Woods and McKiernan, 1995; Woods, 1996). The findings of studies conducted up to 1990 are mainly positive with regard to social interaction (Kiernat, 1979; Gardella, 1985; Orten et al., 1989), interest (Kiernat, 1979) and cognitive functioning (Gardella, 1985; Baines et al., 1987).
Stimulation Oriented Approach: It comprises of art and music therapy. Art therapy has been recommended as a treatment for people with dementia as it has the potential to provide meaningful stimulation, improve social interaction and improve levels of self-esteem (Killick & Allan 1999). Activities such as drawing and painting are thought to provide individuals with the opportunity for self-expression and the chance to exercise some choice in terms of the colours and themes of their creations. Several studies have reported benefits gained by people with dementia from music therapy (Killick & Allan, 1999). The therapy may involve engagement in a musical activity (e.g. singing or playing an instrument), or merely listening to songs or music. Lord & Garner (1993) showed increases in levels of well-being, better social interaction and improvements in autobiographical memory.
Cognitive Oriented Approach: It consists of activities and reality orientation. Activity therapy involves a rather amorphous group of recreations such as dance, sport, puzzles and drama. It has been shown that physical exercise can have a number of health benefits for people with dementia, for example reducing the number of falls and improving mental health and sleep (King et al, 1997) and improving their mood and confidence (Young & Dinan, 1994). In addition, Alessi et al (1999) found in a small-scale controlled study that daytime exercise helped to reduce daytime agitation and night-time restlessness.
Reality orientation is one of the most widely used management strategies for dealing with people with dementia (Holden & Woods, and 1995). It aims to help people with memory loss and disorientation by reminding them of facts about themselves and their environment.

C. Activity Guidelines
For a person with dementia, the need for a good quality of life is not diminished. However, without some assistance from family and carers, their ability to achieve purpose and pleasure is much more difficult.
Ideally, activities should:
< Compensate for lost activities
< Promote self esteem
< Maintain residual skills and not involve new learning
< Provide an opportunity for enjoyment, pleasure and social contact
< Be sensitive to the person’s cultural background
Helpful Guidelines for Planning Activities
Consider all that has made the person unique: knowing the person’s former lifestyle, work history, hobbies, recreational and social interests, travel and significant life events.
Activities can re-establish old roles: Make use of skills that have not been forgotten, such as buttering bread, washing up or watering, sweeping and raking in the garden. These are also ways in which a person with dementia can contribute to the household and feel useful. Encourage an area of responsibility no matter how small.
Activities can give relaxation and pleasure: A person with dementia may enjoy an outing even if they do not remember where they have been.
Simple and unhurried activities that are meaningful are best: Give the time and space necessary to allow the person to do as much as possible. Focus on one thing at a time. Break down activities into simple, manageable steps. Communicate one instruction at a time.
Prepare a safe working area: People with dementia often have difficulty with visual perception and coordination. Ensure that surfaces are uncluttered with few distractions and noise. Good lighting, without glare, individual seat preferences and correct work heights are all important. Using plastic containers might help to avoid breakages.
Don’t allow activities to reinforce inadequacy or increase stress: Abilities can fluctuate from day to day. Activities can be adapted and tried another time if not successful or enjoyable.
Use times to suit the person’s best level of functioning: To ensure maximum success when carrying out activities it is best to consider the times of day when the person is at their best.
Don’t over stimulate: Be selective with outings. Avoid crowds, constant movement and noise which many people with dementia find overwhelming.
Allow an emotional outlet: For many people, music or contact with babies, children or animals provide positive feelings. The opportunity to relive treasured moments can be deeply satisfying. If reading skills have deteriorated make individual audiotapes. Locate picture books and magazines in the person’s areas of interest.
Include sensory experiences: Some sensory experiences
Consistency is important: It can be helpful to write out an activities care plan if different people are caring for the person. This will ensure that activities are consistent and are suited to the individual needs of a person with dementia.
Activities play a significant part in the dealing with changed behaviours: Knowing what helps to calm or divert a person when they are restless or distressed is very important. This can be particularly helpful for respite workers.
Don’t give up: Don’t give up – Mistakes and failures will happen, but don’t let the person with dementia feel like a failure. Keep trying.

Several key risk factors for dementia have been identified:
< Ageing
< Genetics
< Medical history, particularly cardiovascular problems
< Lifestyle and environment

There is no single straightforward cause of dementia, and no way of definitely preventing it, but it may be possible for each of us to reduce our risk or at least delay the onset of dementia.

Ageing: Dementia is an illness, not a normal part of growing older. Even at a very advanced age, most people do not have dementia.
However, age is the biggest risk factor for dementia Dementia affects about 2% of people aged 65 to 70, 5% of people aged 70 to 80, about 20% over 80 and 33% over 90.

Genetics: Most of the research on the genetics of dementia is about Alzheimer’s disease. However, there are known genes that contribute to some of the risk factors for vascular dementia, such as high cholesterol levels, high blood pressure and diabetes.
Familial Alzheimer’s disease: It is a rare type of Alzheimer’s disease where there is a family link caused by a single defective gene, and usually affects people under the age of 65. So far, three different genes of this kind have been identified. Only a very few families worldwide are affected by each gene and most cases of early onset Alzheimer’s disease are not inherited in this way.
APOE: Researchers have identified a protein called apolipoprotein E (ApoE) which affects your chances of developing Alzheimer’s disease. There are three forms of ApoE: ApoE2, ApoE3 and ApoE4.
Having one or two copies of ApoE4 increases someone’s chance of developing the disease, but does not make it certain. Some researchers think that ApoE4 does not affect whether a person will get the disease but, rather, when they get it, causing people with ApoE4 to develop the disease before people with ApoE2.

Down’s syndrome: People with Down’s syndrome are now living longer and are at particular risk of developing Alzheimer’s disease at an earlier age than usual. Estimates suggest that more than 50% of people with Down’s syndrome in the 50-59 age group have dementia.

Medical history, particularly cardiovascular problems: Conditions that affect the heart and blood circulation are particularly important for the risk of developing vascular dementia. High blood pressure, high cholesterol levels, diabetes, heart attacks, strokes and mini-strokes can all affect blood supply to the brain, leading to possible damage. Obesity in mid-life may also increase the risk of developing dementia.

Lifestyle and environment: Many people are already aware that their lifestyle – for example diet and exercise – can affect their risk of heart disease. The evidence is growing that the same factors also affect dementia risk. Following are few factors that may reduce the risk of dementia.

< A balanced diet
< Good amount of physical activity
< Cease smoking
< Reduce alcohol consumption
< Mental stimulation
< Socialization
< Preventing head injuries
< De-stress

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