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Understanding Dementia

Dr. Ajaya Mahanta

 

Dementia is defined as acquired deterioration in cognitive abilities that impairs the successful performance of activities of daily life. Memory is the most common cognitive ability that is lost in dementia. Other mental faculities that are affected includes language, calculation, judgment, vituospatial abilities, problem solving . There is also neuropsychiatric disorder resulting in depression, apathy, agitation, disinhibition. The most common form of dementia is Alzhemer’s Dementia begins with memory impairment but other form of dementia like frontoto temporal dementia may not have memory loss to begin with.


AlzheimerAlois Alzheimer, who first described the neuropathological changes in brain of a demented patient more than 100 yrs back.Dementia until recently considered as not a common problem in underdeveloped and developing countries. But as unprecedented number of people all over the world approach old age, there is growing public concern about loss of mental acuity that often attributed to aging. Progress in health care has dramatically increased the likelihood of entering into eight and ninth decades of life in generally good physical health, increasing the probability that the body will out lived the mind. In India the life expectancy at birth has risen from 52.5yrs in 1981 to 60.7yrs in 2001 and projected to reach 67.7 yrs after two decades. Indian aged more than 60yrs have increased from 5.7% of total population to 7.7% (46 million) in 2001 and are estimated to reach 11.4% (132million ) by 2021. This shows that in future there will be enormous rise in the number of people with dementia in our country imposing increasing burden in our society.

 

Why we should understand dementia ?


1. World is facing a new epidemic of unprecedented proportion
2. Its effect will be felt predominantly in low and middle income countries least prepared to meet the challenge
3. Societal cost will rise inexorable, driven by the increase need for long term care
4. In India number of cases reported are 3 millions in 2010


Unfortunately, our public awareness about dementia is low, families do not seek help and health care system
because most of them do not recognize the problem.


Dementia is not a single disease. It comprises wide variety of diseases. Alzheimers’s disease (AD) is the
commonest subtype worldwide (65%), followed by Vascular dementia (15%) , both combined (15%) and others only 5%. Recent prevalence study in India has revealed higher prevalence of dementia in Sothern and Western India, compared to that from Northern and Eastern parts of our country. This may not be true as systematic study has not been done in this region especially in North east India.


How to recognize dementia?

 

In early stages dementia is not often obvious. Family members, often remembers that they have noticed the subtle changes for months or may be for years , but ignored it thinking that it was just an old age or behavior problem that will pass away. Early identification gives us an opportunity to slow the progress of the disorder. In some cases associated symptom like depression, agitation, psychosis ect. if identified early can be treated in time and prevent deterioration. An early diagnosis, when decision making capacity is still retained, also help the individual to take decision for future, of property, finances and life plan for near and dear ones. Once disease advances these are not possible and may put the family members in trouble. Moreover, early identification provides safety to the individual and avoid accidents while driving, in case of female patients avoid accidents while cooking.


Early stage of dementia –

 

Early stage of dementia has several identifiable symptoms of which forgetfulness is most common. Forgetting recently learned information, forgetting important dates or events; asking for the same information over and over; relying on memory aides (e.g. reminder notes or electronic devices) or family members for things they used to handle on their own. Interestingly, their old memories are preserved (e.g. memories of their childhood and service life ).

 

Moderate stage of dementia -

 

In this stage person has problem in recognizing things , recalling his or her current address, forgets steps of
games one is so familiar few years back. Choosing right type of cloth in right weather needs assistance. Cannot carry out basic calculation. They may have trouble following a familiar recipe or keeping track of monthly bills. They may have difficulty concentrating and take much longer to do things than they did before.

 

Moderately severe stage of dementia –

 

At this stage affected persons’ personality significantly changes. Person will loose track of the recent happenings and events. Sleep is disturbed. There are frequent urinary and stool incontinence. The mood and personalities of people with dementia can change. They can become confused, suspicious, depressed, fearful or anxious. The mood and personalities of people with dementia can change. They can become confused, suspicious, depressed, fearful or anxious.They may put things in unusual places. They may lose things and be unable to go back over their steps to find them again. Sometimes, they may accuse others of stealing. This may occur more frequently over time. Many a time demented person may found wandering and sometime may get lost.

 

Severe stage of dementia –

 

This is a final stage of dementia. Demented person cannot take care of themselves. They need constant care , assistance to use the toilet, to take bath and get dressed. There is also difficulty in mobility and moving around. The behavioral changes become more evident , they become more aggressive. Ability to communicate also is lost. In late stage they are bedridden.

 

What is the cause of dementia –

 

Dementia results from degeneration of neuron (brain cell) and neuronal network. The location and severity of neuronal loss determines the clinical manifestations. Alzheimers’ dementia begins in the transentorhinal region and spreads to the hippocampus , eventually become more wide spread. Therefore in Alzhemers’ dementia memory loss is first cognitive decline. In contrast another type of dementia known as fronto temporal dementia which begins at frontal region do not have memory problem to begin with but have difficulties in decision making , mood and behavior.

 

Causes of Dementia –

 

Age – Increasing age is strongest risk factor for dementia. Whether dementia is an inevitable consequence of increasing age is controversial. Some centenarians maintain intact memory till death.


Other common causes of dementia are –

 

Alzheimers’ dementia constitute 65% of all dementia

 

Vascular dementia resulting from cerebrovascular disease is second most common type , constitute about 15% of dementia.

 

Dementia related to Parkinsons’ disease, Dementia with Lewy bodies, Fronto temporal dementia are next common causes of dementia.

 

Chronic intoxication like those resulting from alcohol and drugs are an impotant cause of dementia which can be cured.

 

Less common causes but reversible dementia are those arising from vitamin deficiency, hepatic disorder, kidney disorder , thyroid disorder and brain infection, brain trauma or brain injury. They are uncommon but important to consider while diagnosing dementia because they are reversible.

 

Laboratory test

 

There is no single laboratory test to diagnose dementia. Multiple tests need to be employed so that reversible or treatable dementia is not missed. The American Academy of Neurology recommends the routine measurement of the thyroid function, a vitamin B12 level, and a neuroimaging CT scan brain or MRI of brain. There are many other neuroimaging studies have developed in recent years . Amyloid imaging , Pittsburg compound-B and 18 F-AV-45 are reliable radioligands for detecting early stage of Alzhemers’ dementia. Once disease modifying treatment become available use of these biomarker will help to treat these patient early , before irreversible brain damage occurred.


 

Gene and Alzheimers’ Disease :

 

Several genes are found to play important role as a cause of Alzheimers’ disease.They are APP gene in chromosome 21, Presenilin- 1 on chromosome 14 and Presenelin-2 on chromosome 2. Mutation of these genes causes AD. Whereas APP gene mutation associated with late (onset AD (> 65yrs of age) , mutation of Presenelins gene associated with early onset dementia(onset before 60yrs age and often as young as 45yrs of age ) .


Treatment of Alzheimer’s Disease:

 

There is no cure of AD. But there are many ways which focuses on ameliorating behavior problems and also giving support to care givers (person or persons taking care of patient) . First step of treatment is to develop rapport with patient, family members, and care givers. Kitchen, bathrooms, stairways and bedroom need to be made safe. Driving should be avoided. Reassurance and communication are necessary. Caregiver becomes exhausted attending a demented person. A respite break for them should be considered in therapeutic schedule. Use of day care centre can be helpful. There are many such centre available in India at major cities . We are starting such centre at Guwahati. Our society is known as Alzheime’s and related disorder society ,Guwahati Chapter ( registered under…….)

 

Medication: Donepezil, Galantamine, Memantine, Tacrine are drug presently in use. They have modest effect on demeted person. May slows cognitive decline, but cannot cure them. The herbal medication Ginko biloba although was found effective in some studies , long term study failed to proof so.

 

Vaccination: Vaccination against Alzheimer’s disease found to be effective in mouse model. But found to have severe side effect in human.

 

Depression responds to antidepressant or cholinesterase inhibitors . SSRIs (Selective serotonin reuptake inhibitors) are commonly used due to their low anticholinergic side affect. Behavior problems like agitation, insomnia, hallucinations are to be treated with newer generation anti psychotics. They should be used with caution in elderly demented person because of side effects. The most important in prescribing medication is to avoid medicine which have anticholinergic effects, or incontinence therapies.


 

Summary of treatment of Dementia:
Dementia treatment depends on underlying cause of dementia. Thyroid replacement for hypothyroidism, vitamin therapy for B12 deficiency, antimicrobial for infection, ventricular shunting for Normal Pressure Hydrocephelous, apppropiate surgery for subdural hemorrhage and brain tumour. Associated psychiatric disorder should be promptly treated with appropriate medications. Non drug behavior therapy has an important place in managing demented patient. Preparing notes for daily activities helps in the early stage of dementia. Family members or care giver should not become hostile to the patient. Explanation, reassurance are

Treatment: Dementia


Nondrug behavior therapy has an important place in dementia management. The primary goals are to make the patient's life comfortable, uncomplicated, and safe. Preparing lists, schedules, calendars, and labels can be helpful in the early stages. It is also useful to stress familiar routines, short-term tasks, walks, and simple physical exercises. For many demented patients, memory for events is worse than for routine activities, and they may still be able to take part in physical activities such as walking, bowling, dancing, and golf. Demented patients usually object to losing control over familiar tasks such as driving, cooking, and handling finances. Attempts to help or take over may be greeted with complaints, depression, or anger. Hostile responses on the part of the caretaker are useless and sometimes harmful. Explanation, reassurance, distraction, and calm positive statements are more productive in this setting. Eventually, tasks such as finances and driving must be assumed by others, and the patient will conform and adjust. Safety is an important issue that includes not only driving but controlling the kitchen, bathroom, and sleeping area environments, as well as stairways. These areas need to be monitored, supervised, and made as safe as possible. A move to a retirement home, assisted-living center, or nursing home can initially increase confusion and agitation. Repeated reassurance, reorientation, and careful introduction to the new personnel will help to smooth the process. Providing activities that are known to be enjoyable to the patient can be of considerable benefit. The clinician must pay special attention to frustration and depression among family members and caregivers. Caregiver guilt and burnout are common. Family members often feel overwhelmed and helpless and may vent their frustrations on the patient, each other, and health care providers. Caregivers should be encouraged to take advantage of day-care facilities and respite breaks. Education and counseling about dementia are important. Local and national support groups, such as the Alzheimer's Association (www.alz.org), can provide considerable help.



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