Dealing with Dementia Advice for families of patients

Dementia is a condition that usually affects older adults.

The two common  types of it  are Alzheimers disease and Vascular Dementia. Whilst loss of memory or forgetfulness is commonly associated with Dementia other factors must also 

be considered.

We had a chat with Dr. Shehan Silva, Consultant Physician/Geriatrician regarding Dementia and 

his advice for families with a 

Dementia patient.

Dementia is a commonly associated condition which affects primarily older adults. This condition results in gradual decline in higher functions of the brain. Higher functions of the brain include memory, language skills, mathematical and logical skills and personality.

There are several types of Dementia. The two common ones are Alzheimers disease and Vascular Dementia. In Alzheimers disease there is a gradual decline of the higher functions due to deposition of certain proteins in the nerve cells of the brain which results in an action similar to suffocation of the same.

Vascular Dementia results due to multiple factors such as high blood pressure, diabetes, high cholesterol level acting singularly or in concert just like strokes or heart attacks. Therefore, it is essential that those factors are well controlled to prevent or slow down 

the process of development of 

Vascular Dementia. 

Parkinsons disease may also give rise to Dementia which is associated with abnormal movements (tremors and slowness) and visual hallucinations. Dementia is usually a disease which is progressive and cannot be completely cured or reversed although it can be slowed down with control of distress. 

There are however some conditions such as low thyroid hormone states, certain vitamin deficiencies like vitaminB12 which are completely curable.

When a person or a loved one realises that there are problems regarding higher functions of the mind it is crucial that he meets an elderly care specialist, neurologist or a psychiatrist to arrange certain cognitive tests to detect the presence of Dementia. These tests are sort of puzzles or mental state examination tests. Some of the examples include the  Mini Mental Score Test (MMSE), Montreal Cognitive Assessment (MOCA), Mini-COG and Addenbrookes Cognitive Examination (ACE-III).

Tips for families with a Dementia Patient

The subtle manifestations of Dementia include gradual loss of memory and computational skills. Although with age there may be subtle memory issues such as forgetfulness of names. However if there are marked problems such as forgetting crucial elements such as forgetfulness of certain activities that they completed such as what they had for a meal or even financial matters, they may herald the presence of Dementia. 

Other symptoms include certain behavioural changes such as inappropriate disposition (clownish behaviour, aggressiveness, undue anxiety, sexual inhibitions etc.)

It is essential that people who have traits of Dementia are evaluated properly by a clinician. Once a diagnosis is reached the disease progression can be modified by control of risk factors and commencement of medication. The targeted medication includes drugs such as Donepezil, Memantine or Rivastigmine which need to be commenced early after appropriate selection by a doctor. 

Furthermore, contributory medical factors mentioned needs to be addressed by appropriate drugs as well as lifestyle modification. Within the family the patient needs to be taken care of patiently and with consideration. The forgetfulness should not be stigmatised or patronised by the loved ones but always corrected or explained in a loving manner. All family members should assist their loved one to realise that the forgotten thing is remembered. There may be repetition of these forgetfulness which needs to be patiently dealt with.

Invariably as time goes patients with Dementia will have a decline in their activities of daily living. These include basic activities such as toileting, washing, grooming and eating, or instrumental activities such as money matters, telecommunication and mobility outside home.

It will come to a point that they would need assistance in a dedicated level with greater demand. Although patients will need a small amount of help initially, at advanced stages a one to one dedicated care taker will be necessary. It is essential that patients are provided assistive mechanisms such as large visible clocks/ calendars, large readable white boards assistance in remembering important things, use of electronic devices with alarms to alert them to accomplish tasks etc. 

Patients with dementia need to engage in mind stimulating activities such as colouring, puzzles, reading books/watching appropriate entertainment and listening to music. They should also engage in activities such as senior citizen groups in churches, temples and communal residencies. They need to be in decision making processes of the family as well.

More importantly love and understanding is essential and all condescending and abusive behaviour including anger should be void at all times.

We hear of patients who may wander out of homes without being able to find their way back or being subjected to circumstances such as theft and injury. It is essential that the doors and gates are kept secure and that there is vigilance about the activity of demented individuals kept at higher level. Furthermore certain people such as those with Parkinsons Disease or normal pressure hydrocephalus may have mobility issues and unstable posture causing them to have a risk of falls and bad consequences such as strokes. It is imperative that the house is made safe by removal of clutter, ensuring good lighting, safe surfaces which are not slippery (especially washrooms) and removal of free lying unsafe objects such as sharps, poisons etc.

Invariably patients with advancing Dementia would have behavioural changes such as aggressiveness, extreme sadness, fearfulness, poor sleep, refusal of important things such as eating and bathing, inappropriate behaviour (e.g. sexual inhibitions,  faecal and urinary soiling). This is known as 

Behavioural and Psychological Symptoms

 of Dementia (BPSD).

Just as the medical conditions need to be kept under control along with regular  administration of Dementia medication, BPSD also may need certain antipsychotics. 

Loved ones need to discuss this with their doctor and see which agent will be better in controlling them. Over the counter medications including irrational use of sedatives or sleep pills are discouraged. Furthermore all such behaviour should be addressed patiently. In a difficult patient rather than enforcing them to engage in the desired activity immediately, they should be approached at a later time with a different and canny approach in a non patronising and non threatening manner. 

With regards to meals, small frequent meals which are novel and are appeasing should be tried. Medication if they are in large quantities can be spaced out rather than be given en masse.

It is essential that the well-being of carers, loved ones and the rest of the family is ensured. Care giver aggression and depression are most of the time undetected. There should be breaks and release of duty of carer so that they will not be continuously exposed to difficult demented patients. Please speak to the clinician regarding this.

As mentioned before, it is essential that patients who have traits of Dementia are seen by  a clinician and assessed with regards to cognition.