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Lost in Thoughts

By: Marc Evans Abat, MD, FPCP, FPCGMLost in Thoughts

Wow, I am having a throwback moment!  One of the first articles that I wrote for the magazine is about dementia, a very challenging condition to manage in a senior citizen.  It has widespread consequences, not only on the older person, but on his family, friends, and society in general.  This is a good opportunity to answer frequently-asked questions and recap essential concepts regarding this disease.

Dementia: Part of Aging or Disease?

The answer to this is quite clear.  Dementia is a disease that is not part of normal aging.  People often notice that memory loss becomes notable among the older age group, hence the misconception that it is a normal change brought about by aging.  However, dementia is not a normal physiologic change.  The different classes of dementia have fairly-elucidated mechanisms on how the damage develops and how the symptoms arise.  These mechanisms occur more commonly among older patients; the older they get, the higher the risk of developing dementia.

So, what exactly is dementia?

Dementia is a condition or a disease that manifests with memory loss and loss of other cognitive abilities (e.g. language, abstract and executive thinking, visuo-spatial ability, calculation, etc.), leading to behavioral and functional deterioration.  It is a progressive deterioration and is caused by several underlying mechanisms that lead to brain damage.

Are there kinds of dementia?

There are several types.  The most common one is what everyone knows as Alzheimer’s disease.  It is responsible for majority of dementia cases which is at 60 percent or more.  Several predisposing risk factors (e.g. genetics, high cholesterol levels, brain trauma) lead to the formation of abnormal protein deposits in the brain.  These are called amyloid plaques and tau protein which are responsible for the consequent brain damage leading to the symptoms.

Vascular dementia is responsible for about 10-30 percent of dementia cases.  This happens due to injuries to the brain resulting from a stroke or “brain attack” or through any mechanism that damages the circulation of the brain.

Both can occur together in a single patient, leading to features that are a combination of Alzheimer’s and vascular dementia.  Older persons with combined symptoms may possibly have mixed-type dementia.

Lewy body dementia has a slightly different earlier symptom pattern than Alzheimer’s disease, manifesting initially with sleep and movement disorders.  The culprit protein is also different (alpha synuclein).  This can also be involved in mixed-type dementias.

Parkinson’s disease, as part of its symptom profile, can manifest in later stages with memory problems.  Alpha synuclein is also involved but has a different distribution pattern in the brain compared to Lewy body dementia.  The movement disorder also pre-dates the memory problem much earlier.

Frontotemporal dementia affects mainly the frontal and temporal lobes, leading to more prominent symptoms of personality disorders and problems with language.

More importantly, there are many conditions that may mimic dementia.  It is important for these conditions to be ruled out, as many of these are treatable and nearly reversible if diagnosed earlier.  These include alcohol-related memory and behavioral problems, thyroid diseases, vitamin B12 deficiency, tumors, normal pressure hydrocephalus, infections, and electrolyte problems.

How do dementias manifest?

Especially in Alzheimer’s disease, the initial and most prominent problem is progressive memory loss.  Memory problems may be as subtle as frequently forgetting meetings and other appointments.  Misplacing objects is also frequent initial symptom.  Co-workers may start noticing work-related difficulties, like gross errors in reports or signing checks.  In the house, they may start losing personal belongings and not remember where these are placed.

The memory problems then become more severe.  They may start getting lost in places they have commonly visited.  Repetitiveness in many aspects become noticeable (like repeating questions, stories, or certain activities like chores that were already finished).  Irritability may then start occurring as frustration builds up inside the older person as he could not understand the source of the problems.

Behavioral problems may start to show.  These include becoming paranoid about many things.  A wife may start becoming excessively jealous towards other women, thinking they are trying to seduce her husband.  Others may think they are being robbed or people are trying to kill them.  Hallucinations, particularly visual, may start occurring.  These include seeing people who are dead or are generally not present.  Some may become disinhibited, failing to suppress previous urges that lead to inappropriate behavior in public (e.g. suddenly stripping naked, or urinating in the street). 

Many may start having difficulties in speaking in such a way that they find it hard to use particular words.  Later on, these people tend to eventually stop talking altogether.

Wandering can be a prominent problem; when they leave their house or their current location, they are unable to go back.  They then wander off to other places they cannot navigate back.  Consequently, many older persons get permanently lost through this mechanism.

Problems with decision-making may also start manifesting.  Older persons have been known to sell their properties for ridiculously low prices.  Or they may start inviting people from the streets into their houses.  More commonly, older persons with dementia tend to receive and accept wrong changes for their purchases, or vice versa.

In more severe stages, they start having symptoms related to basic bodily functions.  Many start to become incontinent.  Nutrition problems often arise from feeding difficulties, which may include inability to recognize hunger, problems with swallowing, or combativeness when being fed.  Many suffer from constipation and fecal impaction due to inability to recognize the need to defecate and to strain properly during defecation.  Eventually, dementia patients become bedridden, unable to speak and recognize, and are totally dependent for all aspects of care.  Death from dementia involves damage to vital centers of the brain that control breathing and heart function.  Other causes of death in dementia patients include infections, pressure ulcers or bedsores, and malnutrition.

As mentioned above, there are some symptoms that may be unique to a particular dementia.  Parkinsonian symptoms (e.g. tremors, rigidity, gait problems) can happen later in Alzheimer’s disease.  Sleep cycle problems (increased sleeping time and cycle reversal) can happen in all dementias but may be an initial problem in Lewy body dementia.  Personality changes may be more prominent initially in frontotemporal dementia.

The Impact of Dementia

It is needless to say that dementia leads to a rather heavy burden on the patient, family, work, and society in general.  Coping with the symptoms in the early phase is difficult for the patient since they could not quite grasp what is happening to them.  This anxiety becomes more severe as symptoms worsen.  The patient loses his independence, his stature in the family, work, and society as he becomes more dependent on others.

The family takes the burden of caring for the patient once his symptoms worsen.  They have to ensure the patient’s safety, comfort, physical, and psychological needs.  They have to endure the consequences of the behavioral symptoms and make some adjustments to cope with these challenges.  As an example, imagine having to take care of a patient who does not remember you, and yet you have to put up with his temper and antics.  This puts tremendous amounts of stress on the family, especially if they do not have the resources to have professional caregivers.

On the societal level, the Philippines is barely equipped to handle the ever-growing needs of an expanding population of senior citizens.  As this segment of society expands, the need to have specialized care for senior citizens also puts significant economic and infrastructural burden on the younger sector, who needs to work to support these needs.  Changing family dynamics (e.g. females working, smaller or deficient living spaces, migration) also affect provision of care.

Dementia management

Management of dementia should address the problems involving memory, behavior, and function.  Medications available are only meant to slow down the disease process.  Other medications are used to control aggressive behavior or depression arising from dementia.  It is important to first see a geriatrician and other specialists to further work-up the patient properly before starting any management plan.  Nutritional interventions, exercise, therapy in the form of music, play and occupational therapy are aimed at maintaining functionality for as long as possible.

Recently, dementia villages have been established in other countries, wherein seniors with dementia are able to live “independently” in a controlled and supervised community.  Support groups are available here in the Philippines for those whose family member has dementia. Here, they can learn and share their experiences, and engage in a constant dialogue with professionals for their care needs.  More so, family support and involvement is essential for the division and distribution of the burden of care.  Nursing homes are also available to ensure quality nursing care for patients and families who have difficulties caring for their loved ones at home.  Online resources are also available for caregivers and families as references.

I do hope my throwback moment helps us to have a better understanding of this condition.  May we continue caring for them despite the challenges. 

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