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Recognising Dementia

“My 80-year-old dad had a fall, his fourth this year. Each time I take him to the A&E the doctor attends to his bruises, takes x-rays and tells me, ‘It’s alright, no fractures, can go home’.”

“My mum, 74, keeps finding fault with the maid. It’s the third maid we’ve changed, and mum accused all of them of stealing her money and jewellery. After investigating, I was shocked to learn that mum is actually confused and delusional!”

Both this 80-year-old man and 74-year-old woman have one thing in common – dementia.

Why diagnosis is important
Due to a lack of awareness among the public and even some healthcare professionals, dementia symptoms are presumed to be part of normal aging or ‘sakit tua’. Sadly, this label gives caregivers false assurances that everything is ‘alright’. In time, however, the overall physical health and wellbeing of a person with dementia often deteriorates, leading to caregiver stress and fatigue, recurrent hospital admissions and increased financial burden.

What is dementia?
Dementia is a word used to describe a group of symptoms including memory loss, confusion, mood changes and difficulty with day-to-day tasks. The majority of people with dementia are over the age of 65.

Types of Dementia
Alzheimer’s Dementia. This is the commonest form of dementia which is well researched and better understood.
Vascular dementia
Lewy body dementia
Frontotemporal dementia
Others

Does my loved one have Alzheimer’s dementia?
Alzheimer’s often develops slowly over several years. It is not always obvious to begin with and symptoms can be subtle and overlap with other illnesses such as depression. In the early stages, it can sometimes be difficult to distinguish Alzheimer’s from mild forgetfulness, which can be seen in normal ageing.

Everyone with Alzheimer’s will experience symptoms in their own way, but certain changes are characteristic of the disease. Typical symptoms of Alzheimer’s may include:
Memory Loss: Regularly forgetting recent events, names, conversations and faces.
Speaking: Forgetting names of common objects, repeating questions after a very short interval, using inappropriate words or statements.
Regularly misplacing items, placing them in odd places or thinking someone has stolen them.
Disorientation: Uncertainty about the date or time, unsure of whereabouts or getting lost, particularly in unfamiliar surroundings.
Becoming anxious or irritable, losing self-confidence or showing less interest in what’s happening. May refuse meals and change food preferences significantly.
May have difficulty recognising household objects and familiar faces.
Day-to-day tasks become harder, for example using a TV remote control or kitchen appliance. People may also have difficulty locating objects in front of them.
Changes in sleep patterns and a tendency to wander and become aggressive when asked to return to sleep.
Some people become sad, depressed or frustrated about the challenges they face. Anxieties are also common and people may seek extra reassurance or become fearful or suspicious. Hallucinations are also a problem.
Become increasingly unsteady on their feet and at a greater risk of falling.
Poor personal hygiene e.g. forgets to brush teeth, wears inappropriate clothing and refuses to bath.

What to expect during a dementia assessment
Clinical assessment:
History from patient and history from informant/ NOK/ reliable caregiver.
Medications review. Some medications may contribute to confused states.
Physical examination: a full clinical examination is necessary.
Mental and cognitive state examination: mental state examination incorporates general behavior, mood, abnormal beliefs and abnormal experiences. Cognitive assessments include attention, concentration, orientation, memory, intelligence, etc.
Activities of daily living. This is a very crucial component of assessment (carried out by an Occupational Therapist). It refers to the personal and domestic tasks that form an integral part of daily life. Assessment establishes baseline information and identification of the patient’s limitations and abilities. In illiterate patients, repeating this form of assessment periodically may provide a clearer indication of improvement or deterioration. Certain activities may be deemed unsafe or dangerous e.g. driving or even cooking (forgetting to turn off the gas).

Investigations:
Blood and urine tests are important to rule out other treatable causes of dementia or confused state. Screening for infection is a standard protocol.
Radiological Imaging, a CT scan or brain MRI, chest X-rays or ultrasound examinations may be required depending on the history and clinical findings.

Caregiver/next of kin responsibilities
The care of a dementia patient requires an alliance with the family or caregivers. It can be challenging to make any healthcare recommendations if a caregiver is unable to engage in the decision-making process. Occasionally I come across a caregiver who is the spouse, and who also happens to suffer from undiagnosed dementia!

Many a times, caregivers are the ones in greater need of proper guidance and training to confidently attend to their loved one’s behavioral and psychosocial needs. It can be tough managing everything on your own, especially when you feel you are at crisis point. Hiring a housemaid may not fully meet all the specific healthcare needs of a dementia suffer.

In my clinical practice, whenever I advise caregivers, they often feel relieved. This is because they can finally begin to make proper healthcare plans to better look after the patient in the comfort of their own home. Once a caregiver understands dementia better, premature or unnecessary placement in a nursing home may even be avoided.

Person-centred and multi-disciplinary approach
Dementia is more than just memory loss. Undiagnosed, it can alter a person’s mood, personality and cause broken relationships. The ability to live independently and safely in the community may be seriously affected. A person with dementia may need specialist assessment(s) by a psychiatrist, occupational therapist, physiotherapist, swallow therapist, dietitian, psychologist, neurologist, etc.

Treatment
While some treatments help people better live with their symptoms (improve their quality of life) there are no treatments that slow or stop diseases like Alzheimer’s. These diseases will continue to get worse over time unless new treatment is found quickly.

Pharmacological intervention may be recommended after a comprehensive specialist multidisciplinary assessment and clear diagnosis. Medications are prescribed under supervision by a specialist doctor. All patients require periodic medical reviews to assess if treatment is helpful in relieving symptoms and to screen for new issues that may surface with time.

I work closely with occupational therapists who are resourceful in educating patients and families about the illness, treatment, sources of care and support. Non-pharmacological intervention should always be considered along with drug options before treatment, with strategies that include behavior, stimulation and emotion-oriented approaches. A rehabilitation programme with clear goals and objectives should be made for each individual.

If you’re interested, do contact our rehabilitation department for information on dementia workshops for caregivers.

Article by:
Dr Chen Queen Liung

Consultant Physician & Geriatrician