Dementia refers to a spectrum of brain disorders. These involve difficulty with memory and thinking, but they may vary in terms of cause, course and prognosis. Dementia involves impairment in multiple facets of cognition. This can include visual/spatial skills, the ability to think, reason, talk and remember, and praxis functions. Personality and mood may also be affected. Dementia is not a normal part of aging. Although we hear people suffer from Dementia or are diagnosed as having Dementia, Dementia itself is not the diagnosis. We need to identify the type of Dementia and the causes, some of which may be reversible, but most of which are incurable. Alzheimer’s disease is the most common cause of Dementia. It is an irreversible, progressive disease. It causes gradual deterioration of mental functions and of the ability to take care of one’s self.
Alzheimer’s disease is the most common cause of dementia. It is progressive and not reversible. Early recognition of the symptoms and diagnosis is important for treatment. Some dementias are reversible, when the causes are, for example:
Alzheimer’s is by far the most common type of dementia, attributed to approximately 2/3 of cases. It was first identified 100 years ago. The onset of Alzheimer’s can be slow and subtle, followed by a gradual decline. Changes in short term memory are noticeable, i.e. memory of recent events. This is typically the primary first complaint.
Those at greater risk of contracting Alzheimer’s include:
Vascular, or multi-infarct, dementia is the second most common cause of dementia, estimated to be 20% of cases. It is caused by reduced blood flow to parts of the brain, often as a consequence of tiny strokes that block small arteries. The onset of symptoms may seem more sudden and clearer. Memory may or may not be as seriously affected as is the case with Alzheimer’s. This can depend on whether blockage has occurred in the memory regions of the brain.
FTD causes personality and behavioral changes and loss of language functions at an early stage. This is different from the memory complaints typical of Alzheimer’s. FTD represents approximately 10-15% of dementia cases and nearly half of these cases occur in people under 65 years of age.
It is distinguished from Alzheimer’s by some or all of following:
Parkinson’s Disease is characterized by tremors, stiffness, speech difficulties and problems initiating movement. When muscle stiffness affects the face, the person may have a mask-like stare. Persons with Parkinson’s may develop dementia late in the course of the disease. A clear sign of Parkinson’s is the presence of Lewy bodies (abnormal proteins) specifically in the area of the brain that controls physical movement.
Huntington’s Disease is an inherited degenerative and fatal brain disease starting in mid-life. Characteristics include personality changes, depression and the development of involuntary movements.
Huntington’s Disease is an inherited degenerative and fatal brain disease starting in mid-life. Characteristics include personality changes, depression and the development of involuntary movements.
Jakob's Disease is a rare and rapidly fatal brain disorder causing Dementia. It affects coordination and causes behavioral changes. It is caused by an abnormal protein (called prion) that turns normal proteins into infectious ones. This disease is related to Mad Cow Disease.
HIV Dementia is direct infection of the brain with toxic viro-proteins. It is believed to cause dementia in 20- 30% of people with advanced HIV and 50% of those with fully developed AIDS. Initial signs are poor concentration, forgetfulness, depression, apathy, weakness and myoclonus (sudden, involuntary twitching of muscles).
HIV Dementia is direct infection of the brain with toxic viro-proteins. It is believed to cause dementia in 20- 30% of people with advanced HIV and 50% of those with fully developed AIDS. Initial signs are poor concentration, forgetfulness, depression, apathy, weakness and myoclonus (sudden, involuntary twitching of muscles).
The early stage of Alzheimer's Disease usually lasts two to four years. It is characterized by forgetfulness, increasing difficulty with problem-solving and withdrawing from activities. If these symptoms are recognized and diagnosed at an early stage, it can save both the individual and their families time and hardship. During this stage you can expect the person with Alzheimer’s to forget experiences, rather than details (like names). The person may need minor assistance or reminders, but may be able to live alone competently. Efforts to hide confusion from others (the person usually knows something is not right) are sometimes successful at this early stage.
The late stage of Alzheimer's Disease is a time of severe confusion and loss of all functional skills. The person has no awareness of his/her condition. During the late stage of Alzheimer’s, the person has: loss of self-care ability; loss of language, is incontinent; is unable to recognize self or others; requires more sleep. Other signs include: weight loss despite a good diet and difficulty swallowing. The individual responds best to sensory activities and cannot tolerate crowded or noisy environments. Typical of this stage is care in dementia care units/nursing homes with 24-hour supervision and assistance. The final stage lasts for one to three years and ultimately ends in death. Severe Alzheimer’s can be quite distressing to witness.
The middle stage of Alzheimer's Disease is characterized by an increase in memory loss and confusion, shorter attention span, increase in language difficulties and repetitiveness. The middle stage lasts for two to ten years. In the middle stage, the confusion is apparent to caregivers. The person may be aware of his/her impairment, but lacks the ability to hide it from others. There is full loss of executive function (i.e. reasoning/problem solving) and difficulty taking care of oneself. The person may need help with activities of daily living (ADLs), such as dressing and bathing. As tasks become more challenging, both physically and cognitively, the person may become delusional, paranoid and develop associated behavioral changes. Optimizing physical, mental and social stimulation is key to slowing the rate of decline into the next stage. Constant supervision is needed. The person shows poor judgment and cannot live alone for safety reasons. At this time, patients are often placed in adult day care programs and/or assisted living. Toward the end of the middle stage, the person loses the ability to control bladder and/or bowel function.
The early stage of Alzheimer's Disease usually lasts two to four years. It is characterized by forgetfulness, increasing difficulty with problem-solving and withdrawing from activities. If these symptoms are recognized and diagnosed at an early stage, it can save both the individual and their families time and hardship. During this stage you can expect the person with Alzheimer’s to forget experiences, rather than details (like names). The person may need minor assistance or reminders, but may be able to live alone competently. Efforts to hide confusion from others (the person usually knows something is not right) are sometimes successful at this early stage.
The late stage of Alzheimer's Disease is a time of severe confusion and loss of all functional skills. The person has no awareness of his/her condition. During the late stage of Alzheimer’s, the person has: loss of self-care ability; loss of language, is incontinent; is unable to recognize self or others; requires more sleep. Other signs include: weight loss despite a good diet and difficulty swallowing. The individual responds best to sensory activities and cannot tolerate crowded or noisy environments. Typical of this stage is care in dementia care units/nursing homes with 24-hour supervision and assistance. The final stage lasts for one to three years and ultimately ends in death. Severe Alzheimer’s can be quite distressing to witness.
The middle stage of Alzheimer's Disease is characterized by an increase in memory loss and confusion, shorter attention span, increase in language difficulties and repetitiveness. The middle stage lasts for two to ten years. In the middle stage, the confusion is apparent to caregivers. The person may be aware of his/her impairment, but lacks the ability to hide it from others. There is full loss of executive function (i.e. reasoning/problem solving) and difficulty taking care of oneself. The person may need help with activities of daily living (ADLs), such as dressing and bathing. As tasks become more challenging, both physically and cognitively, the person may become delusional, paranoid and develop associated behavioral changes. Optimizing physical, mental and social stimulation is key to slowing the rate of decline into the next stage. Constant supervision is needed. The person shows poor judgment and cannot live alone for safety reasons. At this time, patients are often placed in adult day care programs and/or assisted living. Toward the end of the middle stage, the person loses the ability to control bladder and/or bowel function.
When you work with a client who has been diagnosed with Alzheimer’s Disease (at any stage), it is important to know that their behavior can be unpredictable. This is often a response to discomfort, an unmet need, and increasing confusion. Patients also develop an increase in difficulty communicating, progressive loss of independence and poor insight and judgment. Key to reducing behavioral disturbances is to identify triggers. These include: pain; fatigue; acute illness; sensory deficits; hallucinations and/or delusions. Behaviors may be psychomotor (pacing, wandering, repeatedly crying out, etc.); verbal (belligerence, nastiness towards others, repetitiveness) and/or physical (combativeness, inappropriate touching). Care workers need to be aware of these types of behaviors which can be expected from their clients.
Alzheimer’s patients often experience a strong sense of depression. This may be reflected as irritability, fearfulness, tearfulness, hopelessness, somatic complaints (i.e., feeling ill physically), lack of energy/interest, changes in appetite. They also may experience feelings of anxiety. This includes feelings of nervousness, worry and apprehension. This is more common in early-stage dementia, when the client is acutely aware of their deficits. Alzheimer’s patients also experience apathy, or flatness of mood, which manifests as an inability to interact appropriately with one’s environment.
Sleep disturbance occurs in 50% of Alzheimer’s patients living in a community setting. It is one of the most disturbing behaviors for caregivers and can cause exhaustion and despair in caregivers. Patients may have trouble falling or staying asleep, or with resuming sleep. They may wander, may reverse night and day, appear more confused and/or may have exacerbation of anxiety, physical or verbal outbursts. Alzheimer’s patients can also experience delirium - a sudden increase in mental confusion, accompanied by hallucinations. Alzheimer’s patients often need medication to help them sleep.
This part focuses on medications that have been proven to be effective in the treatment of Alzheimer’s.
Aricept, Exelon, Razadyne: Indicated for mild dementia; used throughout the course of the disease. Side effects are mainly gastro-intestinal (GI) in nature, minimized by giving in the morning with food. There may also be vivid dreams or leg cramps.
Namenda: Indicated for moderate dementia, used either alone or together with one of three medications previously noted.
Antidepressants of the class known as Selective Serotonin Reuptake Inhibitors (SSRIs) are generally used. They address depression and anxiety. Medications such as tricyclics (for example, Elavil) and benzodiazepines (such as Lorazepam or Valium) should not be used because of the potential for increased confusion and dizziness and the increased risk of falls with potential injury.
Namenda: Indicated for moderate dementia, used either alone or together with one of three medications previously noted.
Atypical antipsychotics (such as Seroquel, Zyprexa, Risperdal) can be helpful, but they carry a concern for side effects. These can include: movement disorders, increased confusion, and the potential for increased cardiac complications. Seizure medications (e.g., Depakote) may be given. However, blood serum levels need to be closely monitored.
It is important to recognize and treat pain. This may require careful attention to body language and behavior. Avoid medications such as Darvon, Percocet and Opioids. Tylenol, regularly dosed, is a very effective analgesic (pain medication). Consider non-pharma options such as: moist heat, massage, and re-positioning.
When treating an Alzheimer’s patient with medication, remember that it is administered for the benefit of the patient and not for staff convenience. The administration of medication should be tailored to the individual. Carers should constantly be aiming to identify links between certain behaviors and medications. Carers should employ strategies that do not require medications. Medications can and should be considered when such strategies are ineffective or not effective enough.
Carers need to remember the importance of limiting the number of medications administered to patients and monitor which medications patients react well to and which ones they react poorly to. It is important to provide medication in a slow and infrequent manner, because elderly people do not tolerate medications as well as younger people. Avoid medications with undesirable side effects, those which can cause more confusion or sedation, or worsen the condition.