There are many types of dementias. For Peace and
Healing, we will address the three major forms of dementia, Alzheimer’s
disease, vascular dementia, which was formerly called multi-infarct
dementia, and Lewy body disease.
The essential features of dementia are multiple cognitive deficits
that include memory and at least one of the following disturbances:
- Aphasia, difficulty speaking.
- Apraxia, difficult writing.
- Disturbance in executive functioning.
These deficits must be severe enough to cause impairment in occupational
or social functioning, and there also needs to be a decline from
a previous level of functioning. In all dementia, there has to be
some memory impairment in order for the diagnosis to be made. These
individuals have difficulty learning new material, and they forget
previously learned material. They frequently lose valuables, forget
where they put their keys, forget food cooking on the stove, which
can become quite dangerous, and in severe cases, they may even forget
their name.
In aphasia, which is deterioration in language function, we see
individuals forgetting the name of certain objects. Their speech
becomes very vague. It is also not uncommon for individuals with
dementia to present with echolalia, which is the repetition of what
they hear. Apraxia, an inability to execute motor tasks, can be
fine motor tasks or gross motor tasks. Coming the hair, writing/drawing
or brushing teeth may become very difficult.
The prevalence of dementia, specifically that of the Alzheimer’s
type, ranges from about
1-2% of individuals between 65-69 years of age, and this rises dramatically.
Over the age of 85 years old, these percentages jump to 16-25%.
Alzheimer’s disease is of slow onset, with an elevated risk
of cardiovascular disease, early mood disturbance, and possibly
some late onset psychosis with some behavioral disturbances, as
opposed to Lewy body disease, which is of sudden onset, clear psychosis,
visual and auditory hallucinations are more common than delusions,
and these individuals do not respond well to anti-psychotic medication.
Treatment is extremely important. After we have reached a very
accurate diagnosis, individuals should be aware that caregiver support,
education and counseling are extremely important. Family members
should be supported and, if possible, in-house nursing can be helpful
in providing caregivers periodic relief from the stress involved
in taking care of a dementia patient.
There are many overlaps of symptoms of all dementias. According
to Dr. Kennedy in his article entitled, “A Comprehensive Approach
to Dementia,” a trial of AChEI inhibitors like Donepezil,
Galantamine or Rivastigmine may improve cognition and slow the decline
of the dementia process. They have also been shown to improve psychological
and behavioral disturbances. There are some side effects of these
cholinergic enhancive medications, typically with diarrhea, sweating
and insomnia. These symptoms usually only occur for a short period
of time.
A brief overview from the Geriatric Mental Health Care: A Treatment
Guide for Health Professionals. New York, New York. If there is
a slow onset with smooth decline and motor function is minimally
impaired, it is most likely Alzheimer’s disease. If that is
not the case, and there is an abrupt onset with fluctuating course
and little, if no psychosis, and there is a history of stroke or
significant brain injury, it is most likely vascular dementia, and
if there is a marked fluctuation in cognitive impairment with hallucinations
and prominent psychotic signs, then it most likely is Lewy body
disease.
According to Dr. Kennedy, there really should be preparations for
late stage end of life care. Power of attorney assigned to a family
member is very important when the patient is still capable of making
decisions. Very tough issues like feeding tubes, breathing machines
and artificial kidney machines need to be looked at and addressed.
It is very important to address these individuals before an individual
becomes so demented that they cannot make decisions, to get it down
on paper whether they want a do not resuscitate order when they
do reach a nursing home status, or if they are home and they can’t
give that clearance due to their demented state.
In closing, the importance of teaching the caregivers how to take
care of their loved ones is crucial. One can make a strong argument
that this is more efficacious than medication, since mediation has
been shown to work better in the short term. In summary:
- Long term planning is important.
- As previously discussed, power of attorney and do not resuscitate
orders should be discussed before the dementia progresses
- Medical alert bracelets and safe return bracelets and/or necklaces
are extremely important in the event a patient takes off.
- A lock should be placed in the upper part of a door, where
they cannot reach it. In general, physical restraints are not
recommended at all, since these do exacerbate fear, and the only
time these are used is when there is a severe case of self-mutilation
or injury, which is rare in dementia.
- Elderly abuse is also high in patients suffering from dementia
because the frustration level among caregivers becomes high, and
inadvertent aggression does occur. This needs to be examined,
and where apparent, addressed.
- Teaching individuals to distress is extremely important.
- It is not uncommon for people who are taking of the demented
patient to be on anti-depressants themselves at some point as
they do become extremely depressed and experience insomnia and
sadness as they see what their loved one is going through.
Remember, the circle of life comes full circle, and at some point
our children will be taking care of us. It is important to mention
to our children and bring up some of these issues as we reach our
sixth and seventh decades of life, to make their lives easier in
dealing with unfortunate medical ailments that may occur. Prevention
is important. Many of you may find this morbid. It is not morbid.
It is appropriate and a loving gesture to our children, to help
them deal with us as we reach our geriatric and golden years.
Diagnostic and Statistical Manual of Mental Disorders, DSM-IV test
revision.
Advances in the Treatment of Dementias, A Comprehensive Approach
to Dementia by Gary J. Kennedy, M.D.
What Caregivers Should Know About Dementia by Carole Smyth, MS,
APRN, BC, ANP, GNP.
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