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Living with Dementia

Diagnosis

Dementia can affect a person’s memory, thinking, or reasoning skills. These problems are generally referred to as “cognitive impairment” due to dementia. Other than affecting the cognitive ability of a person, dementia may also affect a person’s personality. Dementia patients may say or do certain things that are out of character. Patients will gradually lose the ability to care for themselves, eventually relying on others to carry out daily activities. In this case, dementia does not only greatly affect the patients but also their caregivers and family members.

Many people confuse the two terms dementia and Alzheimer as describing the same condition. A main characteristic of Alzheimer disease is the accumulation of Amyloid protein in the brain. The first symptoms are short term memory lost – forgetting recent incidents and conversations. As time progress, Alzheimer disease may impact the patients’ long term memory (forgetting things that happened in the past), and affect their thinking abilities. Alzheimer's disease is perhaps the most common form of dementia, but is not the only cause of dementia.

Dementia symptoms can progress rapidly but also in some cases the progression is slow. Generally speaking, it is normal for a healthy older person to complain about their poor memory; however, if the severity of the memory loss is enough to interfere with his/her basic daily activities, then a further evaluation should be conducted. Still, one of the challenges is the patient being unaware of his/her symptoms. A diagnosis often only occurs when family members and friends notice the change and persuade the person to seek medical advice.

The assessment of a dementia specialist is very useful for the diagnosis and determination of the cause of dementia. Although currently there is no cure for dementia, once diagnosed the appropriate treatment and support can be provided for the patients and their families. As a result, the patient is more likely to stay independent longer and live a higher quality of life.

healthcare teamDuring the evaluation of dementia, many different professionals will be involved, including: doctors, genetic counselors, nurses, occupational therapists, psychologists, or social workers. They will work together to provide detailed information and reports for patients and their family members. This process will ensure that the patients and family members will receive help as needed.

Generally, the diagnostic process is divided into four parts:

1. Collect information – medical professionals will collect information about of the daily activities the patient is having difficulties with, such as memory, attention span, language skill, ability to plan and personality. Examples of these questions are:

  • How long have these difficulties been noticed?
  • Was the onset of these problems sudden or gradual?
  • Is the patient currently in a more stable condition? Or is the condition progressively getting worse?
  • As the patient’s ability to think starts to decline, did other symptoms appear simultaneously as well (such as, difficulty walking, loss of balance, or loss of bowel and bladder control)?
  • Does the patient have other health conditions? Such as, heart attack, stroke, high blood pressure, high cholesterol, diabetes, or an irregular heartbeat (arrhythmia. These conditions could all affect the type of dementia diagnosed.
  • Other questions about mental illness may also be asked including those about depression and anxiety.
  • Patients need to report all their current medication including both the prescribed and the non-prescribed drugs. Some drugs may cause dementia to get worse.
  • How much dementia has affected the patient’s daily activity? This information can be determined by a comparison of the patient’s past and present level of functioning or ability to care for themselves.

Through communication, health care professionals may be able to identify the risks factors of dementia, such as, hereditary reasons. The information provided by family members or caregiver is also very useful. If family members or caregivers find it inconvenient to provide that information in front of the patient, they can request for a private conversation with the health care professionals.

clock test image2. Evaluation of cognitive ability – These tests will look for areas where the patient’s performance is worse than what is expected for their age and level of education. The initial tests are designed to be easily administered and to quickly identify patients experiencing significant cognitive problems. The Mini-Mental State Examination (MMSE) and the clock drawing tests are the most commonly administered tests for dementia. While these tests are helpful in making a diagnosis, scores may also be used to monitor the disease progression or the response to treatment. More extensive and detailed tests may be required to identify individuals who have less obvious or unusual cognitive problems.

3. Physical examination – A physical examination will also be performed to look for underlying medical problems or findings associated with certain types of dementias. Although the physical examination is fundamental to all assessments, there is no specific finding that definitively confirms or rules out the possibility of dementia. Most assessments will include a careful look at blood pressure, heart rate and a detailed examination of the nervous system and the brain. Depending on the patient, further detailed examination of other systems may also occur.

4. Other examination – Laboratory investigations may be ordered to rule out medical conditions that can cause and/or worsen dementia symptoms. For example:

  • Blood tests – performed to look for problems with the thyroid gland or deficiency in certain vitamins like B12. Depending on the findings of the history or physical examination, more specialized tests can be ordered to rule out other conditions. Other tests may be required, depending on the individual.
  • Computerized Tomography (CT) scan or magnetic resonance imaging (MRI) – these are commonly used neuro-imaging tests. These scans provide clinicians with information about the structure of the brain in a relatively non-invasive way. The results of these tests are used to rule out possible problems in the brain such as bleeding, tumors or strokes that can affect a person’s brain function. With the latest knowledge and technology, more detailed information can be collected about changes in the brain (often shrinkage). If present, these changes can help the clinician be more certain about the diagnosis. However, these findings may not be present in all patients with dementia. Given the cost and limited availability of these tests, they are best reserved for situations where the results will influence the diagnosis and/or method of care for the patient.
  • Single photon emission computerized tomography (SPECT) or positron emission tomography (PET) scans – these are sometimes used in specialized situations such as research or when the diagnosis is unclear.

The challenges that dementia brings are always changing. Health care professional will have the most up-to-date knowledge about dementia, so it is crucial for patients and families to receive their information and support.

Content provided by Dr. Philip Lee, Geriatrician

 

Treatment

Treatment for Dementia can be divided into two types: Medical and non-Medical treatment

Medical treatment: this can be divided into three categories:

1. Treat the underlying cause of the disease to achieve complete recovery (only possible in certain cases) – some illnesses can mimic dementia and Alzheimer’s disease. After the diagnosis is made, direct treatment may be given to attain complete recovery, for example:

  • Vitamin B12 deficiency—may be treated with B12 supplements
  • Hypothyroidism—may be treated with thyroid hormones
  • Depression—may be treated with anti-depressant medications
  • Meningitis and/or infection of the brain—may be treated with antibiotics
  • Adverse reaction of medications that induces symptoms—discontinue the use of the medication
  • Alcohol abuse—stop drinking

2. Slow the progression of dementia and Alzheimer’s disease – there is no medication to completely cure Alzheimer’s Disease, Vascular Dementia, Mixed Dementia and Lewy Body Dementia; but there are some medications that can slow down the progression of the diseases and to improve the quality of life for the patient.

  • Cholinesterase Inhibitors: It can increase the amount of Acetylcholine (a chemical substance) in the brain. This can result in improvement of the patient’s memory and mood, and slow down the progression of the disease. There are three types of inhibitors that can be used for treatments of the early or middle stage of dementia or Alzheimer’s disease:
    • Donepezil (Aricept): In the beginning, the dosage is 5mg a day. After 4-6 weeks, the dosage can be increased to 10mg.
    • Galantamine (Reminyl): The dosage should be 4mg twice a day after meal. 4 weeks later, the dosage can be increased to 8mg twice a day after meal. After another 4 weeks, the dosage can be increased to 12mg twice a day after meal. This medication is good for Mixed Dementia or Multi-infarct Dementia.
    • Rivastigmine (Exelon): In the beginning, the dosage should be 1.5mg twice a day after meal. Six weeks later, the dosage can be increased to 6mg twice a day after meals. The new Exelon Patch 5&10 can be put on the skin. The advantage of patch is it reduces the side effects to the digestive system; however, some patients may have a skin reaction.
    The medications mentioned above may not be useful to everyone. It can often take a long time for the effects of a medication to be noticeable. Patients and caregivers must be patient while waiting to see if any beneficial changes are occurring.
    • 20-30% definite improvement
    • 40-50% no change; conditions remain the same
    • 20-25% conditions may continue to deteriorate
    • 10-20% medications have to be stopped due to adverse reaction
    The most common side effect is discomfort in the digestive system, such as nausea, vomiting, diarrhea and loss of appetite, but given time, these side effects may gradually disappear.
    Patients in the middle stages of Alzheimer’s disease that do not show a clear improvement from the inhibitors may consider using Memantine (Ebixa) alone or combining with other medications.
  • Memantine (Ebixa): The dosage should be 5mg a day for the first week. If necessary, it may be increased to 10mg twice a day.
  • Antioxidant: (such as Vitamin E) was thought to be able to slow down the progression of Alzheimer’s disease, but repeated research did not confirm its effectiveness.
  • Gingko Biloba: also considered to be beneficial to dementia patients, but further clinical research is required to give a definitive answer.
     
    The objective of treating vascular dementia is the same as that of lowering the risk of blood clots. Patients must use medications to control the symptoms of high blood pressure, diabetes, and high cholesterol levels (hypercholesterolemia). Use of blood thinners such as (Aspirin) is also recommended. Patients also need to: quit smoking and drinking heavily; reduce the amount of salt intake; avoid high cholesterol foods; and exercise regularly.

3. To directly treat the symptoms of dementia – some dementia patients have abnormal, aggressive and irritating behaviors towards others. The newer Atypical Anti-Psychotic medications, such as Olanzapine, Risperidone and Quetiapine, have fewer side effects than previous inhibitors. They can improve patient’s behaviours so that it is easier for the caregivers to manage the patient.

Non-medical treatment: The non-medical treatments are also important in addition to the medical treatment.

  1. Maintaining healthy brain activities: Daily brain exercise is beneficial to the patient because it can slow down the progression of dementia. Patients should be encouraged to participate in activities such as: reading, writing, puzzle solving and simple calculations. High demands should not be placed on them as it might cause an opposite effect as the patient may become frustrated.
  2. Reality orientation: The caregiver is advised to repeatedly remind the patient of “the realities” such as the time, date, place or any special events of the day. The caregiver can also write down the information on a piece of paper for the patient to read. This may assist the patient in remembering and understanding his/her situation.
  3. Support for the patient: It is very important for family members to understand the techniques of taking care of patients with dementia and to fully support them. To avoid accidents caused by patients, it may be necessary to adjust the living environment.
  4. Utilize available resources: It is beneficial for caregivers to get familiar with their community resources. This will help to lessen their worries and burdens. These services are provided by adult day care centres, respite care, home support services, Alzheimer Society of BC and Caregiver Aid.

When caring for patients with dementia, a plan should be designed specifically for each individual. In addition, the most effective care plan includes all various methods of treatment for an all-rounded approach.

Content provided by Dr. Thomas Ho, Family Practice