Dr. C. V. Alert, MB BS, DM. FCCFP.
Family Physician.
Dementia refers to a group of brain disorders that make it hard to remember anything, think clearly, make decisions, or even control emotions. It is not uncommon that when many people grow older they show some of these symptoms, sometimes called senility, but a clinical diagnosis of dementia should not be made unless the affected person is unable to take care of himself/herself. For example, a person may not recall recent events or may keep losing items (such as keys and glasses) around the house, but these symptoms are not sufficient to actually diagnose dementia. They may ask the same question over and over. Many people with dementia become restless. They may constantly wring their hands, pull at their clothes or touch themselves inappropriately in public. A person with late stage dementia may show distress by crying, pacing, screaming or shouting. This may be due to fear, anxiety, depression or difficulty understanding what is happening around them.
Dementia is caused by damage to or loss of nerve cells and their connections in the brain. The actual symptoms depend on the area of the brain that’s damaged. Dementia can and does affect different people differently.
A person with dementia has a hard time with at least two of the following:
- Memory
- Communication and speech
- Focus and concentration
- Reasoning and judgment
- Seeing things that aren’t there – hallucinating.
Symptoms of all types of dementia can be mild, moderate or severe, depending on whether the disease is in the early or late (advanced) stages.
Very early stages of dementia can look like normal old-aged forgetfulness. Your loved one might have memory lapses, including forgetting people’s names and where they left the keys, but they can still drive, work and be social. As dementia progresses it is common to experience frequent memory lapses, confusion, difficulty with language, problems with thinking, judgement, and decision-making. People with advanced dementia should not be left alone. Some treatments may help manage symptoms for a period of time. However, a person’s condition will gradually decline and result in death.
Dementia is not one disease: there are various types of dementia. Probably the two most common types of dementia are Alzheimer’s dementia and Vascular dementia, but there are other less common types of dementia.
There are a variety of potentially treatable medical conditions that can cause dementia-like symptoms, and persons who exhibit these symptoms should have a medical evaluation as the barest minimum. These symptoms should not be dismissed as part of ‘growing old’. Medical conditions such as thyroid disease, syphilis, B12 deficiency, brain tumors and others may have specific treatments, and this should be explored. Some common medications, and many drugs that are used and abused (alcohol, marijuana, and cocaine) may also produce a similar picture. These days even environmental conditions like air pollution are implicated in some cases of dementia.
A lot can be done to lower dementia risk, but it requires individual behavior modifications as well as a comprehensive approach. The family, the community and the healthcare system are all needed for early identification, early evaluation, and early initiation of treatment.
Social isolation, so common later in life in women in particular, is an important risk factor for the development of dementia. Many of the chronic non-communicable diseases (NCDs), especially when they are not adequately managed, are also important risk factors for the development of dementia, in particular vascular dementia. So, informing our patients about the risk factors and what can be done in terms of healthy nutrition and exercise, increased focus on adequately managing the NCDs, can go a long way in helping our patients reduce their risk for dementia.
Dementia is not an inevitable consequence of ageing. It is estimated that close to 50% of cases of dementia worldwide can be prevented or delayed by improving some modifiable risk factors. Some that come to mind are type 2 diabetes, hypertension, and even certain forms of cancer. Modifiable risk factors include cigarette smoking cessation, alcohol consumption reduction, diet, physical activity, and maintaining a healthy weight.
Alzheimer’s disease (AZ).
Globally, about 60%-80% of people who have dementia have Alzheimer’s disease. AZ happens when plaques and tangles build up in the brain, and they block nerve signals and destroy nerve cells. Memory loss may be mild at first, but gets worse over time. Identifying these abnormalities in the brain usually require a CT scan or an MRI. It’s a progressive condition, which means it gets worse over time, and it usually affects people over age 65. There’s currently no cure for Alzheimer’s disease. But some therapies can help people with Alzheimer’s disease manage their symptoms and improve their quality of life, and the quality of life of their family members.
Common Alzheimer’s symptoms include:
- Trouble remembering names, events, or conversations. This is often the main feature of Alzheimer’s disease. However, some persons with AZ seem to remember activities from many years ago, such as their best friend in primary school, but can’t remember what they had for breakfast this morning.
- Problems concentrating.
- Personality changes, such as not caring about things you used to, mistrust of others, or aggression.
- Mood changes.
- Depression.
- Impaired judgment or decision-making.
- Confusion.
Vascular Dementia.
Vascular dementia is caused by progressive damage to the brain due to blood vessel damage or blockages that lead to mini-strokes or brain bleeding. This type of dementia is often called multi-infarct or post-stroke dementia. In Caribbean countries, where there are high rates of obesity, hypertension, type 2 diabetes and hyper-cholesterol, it is suspected (but not actually confirmed) that we may have as much vascular dementia as Alzheimer’s dementia. Because of its connection with the NCDs, the vascular dementias seem to be increasing in frequency, and appearing in younger and younger persons. A person can actually have two or more types of dementia at the same time.
Unlike Alzheimer’s disease, memory loss isn’t the typical first symptom. Instead, people with vascular dementia can have different signs, depending on the area of the brain that’s affected, such as problems with planning or judgment. Treating the pre-disposing conditions can help keep the brain and blood vessels healthy and try to prevent future damage. These include healthy eating, regular exercising, keeping blood pressure, blood sugar and cholesterol levels under control, and not smoking or drinking heavily. Regular check-ups should also be part of this.
Keeping one’s brain active is an important part of dementia prevention, and dementia treatment. Avoid social isolation, which is a major risk factor for dementia, Treat hearing or vision loss, which can exacerbate social isolation and depression. Other less common risk factors include traumatic brain injury from an accident or contact sports, and poor air quality.
The family, the extended family, and the community, and the local Dementia Association, all can have critical roles in dementia, both in its prevention, its early recognition, and in attempting to slow the progression of mild cases. Some note that, in this era, many people have become isolated from family and friends, and this may be one among many reasons for the rising numbers of persons with dementia. Social interaction is an important tool in dementia, especially in mild cases, and can slow or possibly prevent the progression to more severe disease. Activities such as dancing, painting, gardening, cooking, singing, card games, board games, dominoes and other activities can help. These (and other) activities also can help people with dementia focus on what they can still do.
Do not quarrel or argue with the affected person, ‘for they know not what they do’. This can only make a difficult situation worse, and get everyone upset. Instead, seek early medication attention, and give the physician as much information about what’s actually happening so that appropriate investigations can be ordered. Other unhelpful sayings to a person with dementia include “ I just told you that:, “your sister died 15 years ago, and “remember when …”.
Unfortunately persons with advanced dementia can be very taking on their caregivers, who basically have to give up their own lives to take care of the person with dementia 24/7/365, (and 366 in leap years). Caretaker burnout is thus a frequent condition, and further highlights the importance of disease prevention, early diagnosis, and early initiation of treatments designed to slow disease progression.
As noted previously, there is no cure for dementia, but treating all underlying conditions is important. Some medications may slow the progression from early disease to advanced disease. Having said this, research is ongoing in the fight to find ‘anti-dementia’ drugs, and some drugs show promising results in research trials. Drug treatments for dementia often focus on treating associated symptoms, such as depression. We have many medications to help persons live longer, but we have fewer tools in our arsenal to preserve brain function in our older individuals.