The Dementias: Diagnosis, Treatment and Research

The Dementias: Diagnosis, Treatment and Research, 3rd edition, edited by Myron Weiner, MD, and Anne Lipton, MD, PhD, is very useful for professionals dealing with elders in later life. The chapters with practical, hands-on information are interspersed with clinical chapters that provide more in-depth explanations. While clinicians and other health professionals are the primary audience, the breadth of topics and the editors’ straightforward approach makes this book a helpful resource for everyone who has a friend or relative with a dementing illness. This article will discuss some of topics covered in the book.

What is dementia?

Dementia is a diagnosis of impaired mental function. It is derived from the Latin de (out of) + mens (mind) + ia (state of), literally meaning a state of being out of, or deprived of, one’s mind.

Alzheimer’s disease is the most common form of dementia, but it is only one of many types of dementia. There are multiple types and causes of dementia ranging from head trauma, alcoholism and stroke to hereditary diseases. There are some potentially reversible dementias, such as those which are caused by urinary tract infections, pneumonia, drug interactions, nutritional deficits or depression. In older adults, dementia syndromes can be triggered by the overuse of prescription drugs, most commonly benzodiazepines and barbiturates.

Dementia is defined as an impairment or reduction of multiple cognitive abilities. This impairment “comes without clouding of consciousness,” meaning that the person with the dementia appears awake and alert, as opposed to groggy or delirious. The diagnosis of dementia is complicated by enormous variation between individuals. Rather than comparing one person to others of similar age, it is better to compare the person to his or her self at an earlier stage.

The Importance of a Dementia Diagnosis

The goal of diagnosing any illness is to provide better treatment. The goal of identifying or diagnosing cognitive impairment is to improve patient well-being, rather than to simply know what label to apply to the patient. An equally important goal of diagnosing the condition is to rule out potentially treatable conditions.

Interventions early in the course of the dementia may delay the onset or worsening of symptoms. The DSM (Diagnosis and Statistical Manual, a book used to define and classify illnesses) criteria for Alzheimer’s disease is impaired memory, which means the patient exhibits an impaired ability to learn new information and/or recall previously learned information, plus one or more of the following:

• Language disturbance
• Difficulty with voluntary motor tasks
• Failure to recognize familiar objects
• Disturbances in executive functioning (e.g., planning, organizing, sequencing and abstracting)

Most patients with Alzheimer’s disease are unaware of their deficits and therefore are unable to develop coping strategies. The clinical term for this state is anosognosia. Anosognosia may be due to the loss of neurons in the brain that allow the ability to self-observe. It is important to understand that the brain cells that allow us to observe our own behavior, and modify it accordingly, are actually lost to the person with Alzheimer’s. Alzheimer’s patients are therefore unable to see that their actions are inappropriate or recognize a need to modify their behavior. Impairment of self-observation shows itself in poor hygiene and inappropriate interpersonal conduct.

Behavioral Issues Related to Dementia

Disturbances in behavior are the most frequent cause for institutionalization. Often the difficult behavior is not due entirely to the dementing illness, but rather an interaction of the patient’s preexisting personality, the physical environment, and the damaged brain.

Behavioral control is related to executive function, which is the ability to think and plan, initiate, sequence, monitor and stop behavior. People whose executive function is impaired are unable to learn from experience, understand the impact of their behavior on others or to regulate their behavior. Executive dysfunction may show itself as a loss of initiative, impulsivity, emotional indifference or unstable mood. Agitation is one form of the loss of behavioral control.

People who are cognitively impaired lose the ability to use positive coping mechanisms. They blame others for their difficulties, rationalize their inappropriate behavior and avoid new situations. They lose the ability to suppress immediate desires, become hopeless when they cannot master the environment, and self-centered as they lose the ability to empathize.

A small amount of anxiety keeps people alert and interested. Intense anxiety impairs concentration and behavioral control. This is significant for the caregiver as well as the patient. Small changes in emotional tension can produce large fluctuations in the patient’s ability to cope with whatever is causing the anxiety. The same is true for sensory input. Information from our senses orients us in time and space. Too much stimulation, or too much novel sensory input, creates confusion and impairs self-control. This explains why people with a dementing illness remember emotionally charged events while they forget neutral ones.

Patients may rummage through closets and drawers, looking for objects that appear to be lost. Wanting to “go home” falls into the same category of behavior, as the patient remembers having felt more comfortable somewhere else and wants to return there. Sleep-wake disturbances are also common in dementing illnesses and are often a factor in the decision to institutionalize the patient. The primary cause of daytime sleepiness is lack of engaging activities. Sleeping is a way to deal with boredom and evade the challenge of understanding the world gone crazy around you. All dementia symptoms tend to worsen in unfamiliar environments.

Dementia & Behavioral Management

Possibly the most difficult task for caregivers is accepting that their loved one has a dementing illness. They often deny the degree of impairment. Acceptance involves a fundamental change in the relationship.

Demented patients have lost the ability to learn from their mistakes and consequently do not understand the need for change. Temper tantrums may be frequent as caregivers take away responsibilities such as the checkbook and the car. Autonomy is a common source of conflict between the caregiver and the patient. The patient wants to be independent, and is unable to recognize the loss of ability to regulate his own environment and behavior.

Dementing illness is characterized by the loss of regulatory functioning. This includes the ability to concentrate and focus attention, to prioritize, to perform actions in proper sequence and to modify behavior based on social cues. Constructing the environment to include these cues, such as posting signs on the patient’s bedroom door or bathroom door, will help compensate for the loss of regulatory function will reduce frustration for both the patient and caregiver.

Patients who shadow their caregivers have lost the knowledge that what they cannot see still exists. They cannot hold the loved object in memory while gone or remember that their caregiver will return. Anxiety often results in the patient shadowing the caregiver and asking the same questions repeatedly. Changing the wording of the answer will not help, neither will writing the answers down. The answer to the question is not important; maintaining contact with the patient is. The implied question is, “Are you going to abandon me?” Sometimes it is helpful to spend extra time with the person, when he or she is not anxious, as positive reinforcement.

In addition to the issues highlighted above, The Dementias: Diagnosis, Treatment and Research offers invaluable insights into: the complex task for providing care for the dementia patient; supporting the primary caregiver; the impact of a dementing disease on the family system; and changes in the environment that can be made to help keep the patient at home in the community.

Posted in Alzheimer's Care, Communicating with Loved Ones, Criteria for Diagnosing, Geriatric Care Solutions, Handling Dementia Behaviors, How to Care for Someone Yourself, Sundowning Syndrome, Treating Symptoms, Treatment, Types & Causes of Dementias, Types of Dementia