What is Dementia?
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.
What is the Treatment of Dementia?
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 de-stress is extremely important.
- It is not uncommon for people who are taking care 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.