Managing dementia

By DR MILTON LUM

Support and care are vital in the management of dementia.

DEMENTIA is the loss of mental abilities like memory, thinking, reasoning, speech, mood and behaviour. It is more common as one gets older.

Types
There are different types of dementia, viz:

=> Alzheimer’s disease – also known as “the disease of the long goodbye” – is the most common. The cause of Alzheimer’s disease is not known apart from a very small percentage which is due to inheritance. The hallmark of the condition is the build-up of plaques in the brain.

=> Vascular dementias make up about 20% of all cases. This is caused by poor circulation to the brain due to narrowed or blocked arteries. The onset is sudden and it often occurs after a stroke. The risk factors are: high blood pressure, diabetes, smoking and poor diet.

=> Lewy body dementia in which there are abnormal clumps of proteins in the brain. These clumps are also found in some people with Alzheimer’s disease and Parkinson’s disease, suggesting that the three conditions are related.

=> Fronto-temporal dementia is marked by shrinkage of the frontal and temporal lobes of the brain, leading to problems with language and/or behaviour but without memory problems.

=> Dementias that can be reversed with proper treatment. They include blood clot in the skull but outside the brain, brain tumours and infections, increase in fluid in the skull leading to pressure on the brain, underactive thyroid, high blood calcium, folic acid and vitamin B12 deficiency, drug and alcohol abuse.

=> Some medicines have side effects that produce dementia-like symptoms, like impaired memory and concentration. They include sleeping pills, tranquillisers, anti-depressants and medicines that have an anti-cholinergic effect, e.g. some medicines prescribed for allergy, cough or diarrhoea.

Features
There are various symptoms, depending on the type of dementia. Many of those affected do not appear ill, particularly in the early stages. However, family and friends may notice changes, which are gradual in most instances.

Those with dementia have one or more of the following symptoms which are categorised into three groups for easy reference, viz: cognitive, functional and emotional problems.

Cognitive problems include:
=> memory loss – It may include forgetting the names of those they know well or where they live. Recent memory is usually affected first. As the condition worsens, past memory is affected.
=> speech and language – Simple words may be forgotten and inappropriate words may be used or the conversation may be repetitive, simplified or irrelevant.

=> problems learning new information or skills
impairment of thinking, calculation and/or judgment

Functional problems include difficulty in performing complex tasks, initially, and as the condition worsens, difficulty with activities of daily living, like dressing and personal hygiene.

Emotional problems include:
=> changes in mood or behaviour. There may be wide mood changes, irritability or aggression. As the condition worsens, inhibitions may be lost with the sufferer saying or behaving inappropriately. This can include sexual matters.
=> loss of emotional control
=> withdrawal from past activities, interests and social interactions

There are different symptom patterns with the different types of dementia. The symptoms may vary daily or not at all.

Many conditions (e.g. depression) have similar symptoms as that of dementia. As such, it is important not to assume that a person has dementia if he/she has one or more of the above symptoms.

Diagnosis
Any complaint about memory loss, language or activities of daily living should be taken seriously. A history would be taken about the nature of the symptoms, their onset and course, medication, depression and medical conditions that affect memory. Physical examination and laboratory tests would be necessary to rule out treatable medical conditions.

It is sometimes difficult to diagnose dementia. If the doctor thinks a person has the condition, tests will be carried out. A standardised score of cognitive ability using rating scales, like the mini-mental state examination (MMSE), rates memory, attention, calculation, language, visual skills and orientation. The test takes about 10 minutes but is limited in that it does not detect subtle memory loss.

More detailed memory assessments, carried out by specialists, will provide better information about subtle memory loss.

Information obtained from blood tests, X-rays and/or a brain scan (computerised axial tomography [CAT] and/or magnetic resonance imaging [MRI]) are important in ruling out the treatable causes.

Sometimes, positive emission tomography (PET) is used as it has a high diagnostic accuracy and sensitivity for the early detection of Alzheimer’s disease.

Management
There is no cure for most types of dementia. However, there is cure for dementias that are related to:

=> brain tumours, head injury or hydrocephalus, which are managed with surgery;
=> infections, which are treated with anti-microbials;
=> vitamin or hormone deficiency, which are treated with supplements;
=> medicines, which are treated by altering the medication prescribed;
=> drug and alcohol abuse, which are treated by lifestyle changes.

While there is no cure for Alzheimer's disease, treatment with certain drugs may prevent the symptoms from worsening, for a period of time.

The herb, gingko biloba, has been reported to have a small but significant improvement in symptoms like forgetfulness and confusion in Alzheimer’s disease and vascular dementia.

Non-cognitive symptoms are treated with a variety of non-pharmacological therapies e.g. aromatherapy, music, dance, contact with pets, massage, and exercise.

Anti-psychotic medicines are prescribed for a period of time for those who have severe symptoms like psychosis and agitation. Cognitive behavioural therapy may be prescribed for depression and anxiety. Anti-depressant medicines may also be prescribed.

When early dementia is first diagnosed, the preferences for care and treatment will be discussed with the affected person, when he/she is still able to make decisions. With the progression of the condition, the ability to make specific decisions will be affected. As such, it is advisable to make written instructions (called advance decisions and advance statements) about care in the future, stating what treatments and other help are wanted or not wanted; the preferred place of care, and carer; and end-of-life issues. The instructions may also include the power of attorney.

Support and care are the hallmarks of the management of dementia. Many of those affected are cared in the community by relatives or friends who face many challenges. Support and advice are available from doctors, nurses, other health care professionals and support groups like the Alzheimer’s Disease Foundation of Malaysia (adfm.org.my).

Conclusion
Dementia is not a part of the ageing process. It is more common in the senior citizens and is associated with various conditions that affect the brain. Those affected may appear well in the early stages but relatives and friends may notice changes. Assessment is important to exclude treatable conditions. There is no cure for the majority of dementias but much can be done to maintain the affected person’s quality of life. Support and care are the hallmarks of its management.

Dr Milton Lum is chairperson of the Commonwealth Medical Trust. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.