Dementia is a syndrome characterised by the deterioration in memory, thinking, behaviour, and the ability to perform everyday activities. It is the major cause of disability and dependency among older people worldwide, although it does not affect consciousness. Cognitive dysfunction is commonly accompanied and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation.
Epidemiology
According to the World Health Organisation (WHO), there are around 50 million people with dementia worldwide, with nearly 10 million new cases each year. Alzheimer’s disease is the most common form of dementia. It may contribute to 60–70% of dementia cases. Among people with dementia, 58% live in low- and middle-income countries, and by 2050, this figure is estimated to reach 71%. According to research by Alzheimer’s Disease International (ADI), it is speculated that Eastern Asia and Southern Asia will see dementia growth rates more than double in the next 20 years.
Types of dementia
Some of the common causes of dementia are:
- Alzheimer’s disease
- Vascular dementia
- Dementia with Lewy bodies
- Frontotemporal dementia
- HIV-associated dementia
Causes and risk factors
Some reversible causes of cognitive decline are:
- Structural brain disorders (e.g. normal-pressure hydrocephalus, subdural haematoma)
- Metabolic disorders (e.g. hypothyroidism, vitamin B12 deficiency), drugs, depression, and toxins like lead.
Some risk factors of dementia include:
- Age: Ageing is the strongest known risk factor for dementia but it is not an inevitable consequence of ageing. However, young-onset dementia accounts for up to 9% of cases.
- Lack of regular exercise
- Smoking
- Harmful use of alcohol
- Obesity
- High blood pressure, cholesterol, and blood sugar levels
- Depression
- Low educational attainment
- Social isolation and cognitive inactivity
Signs and symptoms
Dementia affects each person differently. It depends on the impact of the disease and the person’s personality before becoming ill. The signs and symptoms linked to dementia can be understood in three stages.
Early stage
This stage is gradual in onset. Common symptoms include:
- Forgetfulness
- Losing track of the time
- Becoming lost in familiar places
Middle stage
In the middle stage, the signs and symptoms become clearer and more restricting. These include:
- Becoming forgetful of recent events and people’s names
- Becoming lost at home
- Having increasing difficulty with communication
- Needing help with personal care
- Experiencing behavioural changes, including wandering and repeated questioning
Late stage
Common symptoms are:
- Near-total dependence and inactivity
- Serious memory disturbances
- Obvious physical signs and symptoms
- Confusion about time and location
- Difficulty recognising relatives and friends
- Increasing need for assisted self-care
- Difficulty walking
- Behavioural changes that may escalate and include aggression
Diagnosis
We can differentiate dementia from other states like delirium (mental confusion) through a person’s medical history and a neurological examination (including mental status). The treatable causes of dementia can be identified clinically and by using laboratory testing and neuroimaging. Sometimes, formal neuropsychological testing may be needed.
Important laboratory testing will include testing for thyroid-stimulating hormones and vitamin B12 levels. Sometimes, routine complete blood count (CBC) and liver function tests are requested.
Radiological imaging of the head such as a CT or MRI scan should be done in the initial evaluation of dementia or after any sudden change in cognition or mental status. They help to identify potentially reversible structural disorders (such as normal-pressure hydrocephalus, brain tumours, or subdural haematoma) and certain metabolic disorders (e.g. Hallervorden-Spatz disease and Wilson disease).
Treatment
The treatment of dementia depends on its cause and stage of the disease. We need a combined approach for the treatment of dementia comprising of:
Patient safety
- Protective measures like hiding knives, unplugging the stove, removing the car, confiscating car keys, etc. may be required.
- Avoid letting the patient travel alone.
- Ultimately, assistance (e.g. housekeepers, home health aides) may be needed.
- A change in living facilities, such as a place without stairs, an assisted-living facility, or a skilled nursing facility may be recommended.
Environmental measures
The environment and surroundings of the patient should be designed to help preserve feelings of self-control and personal dignity. It is helpful for the patient if we provide frequent reinforcement orientation, a bright, cheerful and familiar environment, minimal new stimuli, and regular, low-stress activities.
For aiding orientation, placing large calendars and clocks in the room and establishing a routine for daily activities can be helpful. Medical staff members can wear large name tags and repeatedly introduce themselves. Any sort of changes in surroundings, routines, or people should be explained to patients precisely and simply. This may avert resistance or violent reactions in response to change. Always give them time to adjust and become familiar with the changes. Visiting them frequently encourages patients to remain social.
Keep their room reasonably bright. Also, keep sensory stimuli (like a radio, television, or night light) around to help patients remain oriented and focused. Try to avoid quiet, dark, and private rooms.
Increasing engagement in activities of their interest can help patients function better. Activities should be fun-filled and provide some stimulation, but they must not involve too many choices or challenges.
The patient should do regular exercise to reduce restlessness, improve balance, and maintain cardiovascular tone. It also helps to improve sleep and manage behavioural disorders. Other options such as occupational therapy and music therapy that help to maintain fine motor control and provide nonverbal stimulation are also available. Also, group therapy (e.g. reminiscence therapy and socialisation activities) may help maintain conversational and interpersonal skills.
Drugs
Some of the pharmacological measures to treat dementia are:
- Eliminating or reducing drugs affecting brain activity.
- Avoid sedating and anticholinergic drugs.
- Cholinesterase inhibitors such as donepezil, rivastigmine, and galantamine may be effective in improving cognitive function in patients with Alzheimer’s disease or dementia with Lewy bodies.
- Memantine is an NMDA (N-methyl-d-aspartate) antagonist that helps to slow the loss of cognitive function in patients with moderate to severe dementia. It may deliver optimal results when used with a cholinesterase inhibitor.
- Drugs to control behavioural disorders (e.g. antipsychotics) can be used if required.
- If signs of depression are observed, antidepressants, preferably selective serotonin reuptake inhibitors (SSRIs), can be used.
Caregiver assistance
It is very difficult for a person living with dementia to manage daily activities all alone. Hence, the family members are very important to provide support and care. It is helpful to contact nurses and social workers who can teach them and other caregivers how to best meet the patient’s needs, such as how to deal with daily care and financial issues. Other resources such as support groups, educational materials, and online resources are also available.
End-of-life issues
As insight and judgment deteriorate in patients with dementia, it is wise to appoint a family member, guardian, or lawyer to oversee finances, legal issues and to take care of the patient when needed. This is usually done early in the dementia stages before the patient is incapacitated. A durable power of attorney for healthcare, finances, and more should be made.
In advanced stages, palliative measures may be more appropriate than highly aggressive interventions or hospital care.
Complications
People with dementia will slowly reduce or stop eating. This will affect their nutrient intake.
Due to a progressive difficulty in swallowing, there is an increased risk of choking or aspirating food into the lungs. This can block breathing and cause pneumonia.
Over time, dementia patients lose their ability to perform self-care tasks such as bathing, dressing, brushing their hair or teeth, using the toilet independently, and taking medications accurately.
People with moderate to severe dementia must not be left alone. Even normal daily activities can present safety issues. Accidents can occur during driving, cooking, and walking alone.
In the later stage of dementia, infection-induced coma and death are common.
Conclusion
Ageing is the rule of nature and dementia inevitably becomes more common. Understanding this fact, we should support and respect our seniors, providing special care homes with healthcare facilities and caretakers for the isolated elderly. At the same time, measures should be taken to modify the controllable risk factors and prevent dementia.
