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Dr. SHASHI BHUSHAN KUMAR

MBBS,MD(PSYCHIATRY) - AIIMS

Consultant Neuropsychiatrist & Deaddiction Specialist

DEMENTIA

What is memory loss and what are the causes ?

"Everybody forgets things from time to time. In particular, the things that we tend to forget most are the things that we feel do not matter to us. The things that we tend to remember most easily are the things that are important to us - like a special birthday. However, some people just seem to have better memories than others, and some people are more forgetful than others.

There are certain situations that can affect your memory and make you become more forgetful than you normally are. These include the following:

A. Poor concentration :- If our concentration is poor then we do not notice things as much, and do not retain things as much as we would normally. Poor concentration can be a result of simply being bored or tired. However, it is also a symptom of depression and anxiety.

B. Depression :-. As well as poor concentration, some people with depression also have slowed thinking. This can cause memory problems until the depression clears. Do tell a doctor if you think that you are depressed as treatment often works well. Other symptoms of depression include: a low mood for most of the time; loss of enjoyment and interest in life; abnormal sadness; weepiness; feelings of guilt or being useless; poor motivation; sleeping problems; tiredness; difficulty with affection; poor appetite; being irritable or restless.

C. Physical Illness :- If you feel ill, this can affect concentration and memory. Certain illnesses can directly affect the way the brain works. For example, an under-active thyroid can slow down the body's functions, including the brain, and can make you more forgetful.

D. Age :-. As we get older it often becomes harder to remember things. This is called 'Age Associated Memory Impairment'. Many people over the age of 50-60 have this common problem, and it is not dementia. For example, it tends to be harder to learn new skills the older we become. Another common example is that you may forget the names of people you have recently met. It is thought that the more we use are brains when we are older, the more it may counter the development of this age-related decline in memory function. So, doing things such as reading regularly, quizzes, crosswords, memorizing plays or poetry, learning new skills, etc, may help to keep your memory in good shape.

E. Dementia.- Dementia is the most serious form of memory problem. The rest of this booklet is just about dementia.

What is Dementia ?

Dementia is a condition of the brain which causes a gradual loss of mental ability. In addition, other features commonly develop such as changes in personality, a decline in social function, and a decline in the ability to look after oneself. There are various different causes of dementia.

Who gets Dementia ?

Dementia usually affects older people and becomes more common with increasing age. Sometime after the age of 65 about 1 in 20 people develop Dementia. About 1 in 5 people over the age of 80 have dementia. Rarely, it affects younger people. Dementia is not a normal part of ageing. It is also different to the 'Age Associated Memory Impairment' that is common in older people.

What causes Dementia?

Dementia can be caused by various diseases which affect the parts of the brain involved with thought processes. However, most cases are caused by Alzheimer's Disease or Vascular Dementia. All of the types of dementia cause similar symptoms, but some features may point to a particular cause. Therefore, quite often it is not possible to say which disease is causing the Dementia in each individual case.

Alzheimer's Disease

This causes about 6 in 10 cases of Dementia. It is named after the doctor who first described it. In Alzheimer's Disease the brain shrinks (atrophies) and the number of nerve fibers in the brain gradually reduce. The amount of some brain chemicals (neurotransmitters) is also reduced, in particular one called Acetylcholine. These chemicals help to send messages between brain cells. Tiny deposits or 'plaques' also form throughout the brain. It is not known why these changes in the brain occur, or exactly how they cause Dementia. There is no way of predicting who will develop Alzheimer's Disease. It is not hereditary and anyone may develop it.

Vascular ('blood vessel') Dementia

This causes about 2 in 10 cases of Dementia. This is due to problems with the small blood vessels in the brain. The most common type is called 'Multi-Infarct' Dementia. In effect, this is like having many tiny strokes throughout the 'thinking' part of the brain. A stroke is when a blood vessel 'blocks' and stops the blood getting past. So, the section of brain supplied by that blood vessel is damaged or dies. As each 'infarct' occurs, some more brain tissue is damaged. So the mental ability gradually declines. The risk of developing Vascular Dementia is increased by the same things that increase the risk of stroke. For example: high blood pressure, smoking, high cholesterol level, lack of exercise, etc.

Other causes of Dementia

Over 60 diseases can cause Dementia. Many are rare, and in many the Dementia is just part of other problems and symptoms. In most cases the Dementia cannot be prevented or reversed. In some disorders the dementia can be prevented, or stopped from getting worse if treated. For example, some cases of Dementia are caused by alcohol abuse or infections such as syphilis, both of which can be treated.

What are the symptoms of Dementia ?

THE SYMPTOMS OF ALL TYPES OF DEMENTIA ARE SIMILAR AND INCLUDE THE FOLLOWING:-

A. Memory loss. As a rule, the most recent events are the first forgotten. For example, a person with early stages of dementia might go to the shops and then cannot remember what they wanted. It is common to misplace objects. However, events of the past are often remembered well until the dementia is severe. Many people with Dementia can talk about their childhood and early life. As things progress, sometimes memory loss for recent events is severe and the person may appear to be 'living in the past'. They may think of themselves as young and not recognize their true age.

B. Disorientation. New surroundings and new people may confuse a person with Dementia. However, in familiar places, and with old routines, the person may function well. This is why some people with mild Dementia cope well in their own home. Losing track of time is also typical. For example, not knowing if it is morning or afternoon, or what day it is.

C. Poor concentration. Not being able to settle to anything.

D. Failing intellect. Even clever people cannot grasp new ideas or learn new skills. For example, how to use a new household gadget.

E. Personality changes. At first, being easily irritable or moody may be noticed by family or friends. In some cases, over time, a person with Dementia may become quite disinhibited. This means that he or she may say or do things quite out of character. This is often difficult for families and friends to cope with.

F. Self care. Without help, some people may not pay much attention to personal hygiene. They may forget to wash or change their clothes.

G. Mood. Some people with early Dementia recognize that they are failing and become depressed. However, many people with dementia are not aware that they are ill. They may remain cheerful. The distress is often felt more by relatives who may find it difficult to cope.

H. Severe dementia. Speech may be lost. Severe physical problems may develop in the later stages of Dementia, such as immobility, incontinence, and general frailty.

How does Dementia progress ?

Symptoms tend to develop slowly, often over several years. In the early stages of the disease, many people with mild Dementia cope with just a small amount of support and care. As the disease progresses more care is usually needed. A 'typical' person with Alzheimer's Disease takes about 8-10 years to go from the first signs of memory problems, to being severely affected, and ultimately to die due to frailty of body and mind. However, the speed of progression of symptoms can vary greatly between different people.

How is Dementia diagnosed ?

Dementia is suspected by the typical symptoms which are usually reported by a relative or friend. A doctor may do a standard 'memory test' to confirm the diagnosis. However, some other conditions (sometimes treatable) have similar symptoms to Dementia. Not all 'confusion' is due to Dementia.

For example, Depression in older people can sometimes cause memory problems. A person, who reports a failing memory themselves, rather than a relative or friend, is just as likely to have Depression as Dementia. Depression is often treatable. Also, some physical problems such as thyroid disorders and brain tumors may cause 'confusion' in an older person and mimic Dementia. Some tests may be done if symptoms are not typical, or if other conditions are suspected.

Can medication help people with Dementia ?

There is no medicine that will reverse Dementia. The following are some medicines that may be used to help.

Cholinesterase inhibitors

These include Donepezil, Rivastigmine and Galantamine. They work by increasing the level of Acetylcholine. This is a chemical in the brain that is low in people with Alzheimer's Disease. These medicines do not affect the brain changes, and are not a cure. However, they may slow down the progression of some of the symptoms in some people with Alzheimer's Disease.

There is debate as to how much these medicines actually help in the wellbeing and day-to-day care of a person with Alzheimer's Disease. Some doctors feel that these medicines give only limited benefit which is not worthwhile. However, some people may benefit more than others.

In the autumn of 2006 the National Institute for Health and Clinical Excellence (NICE) issued national guidance on the use of these medicines. NICE recommended that "Donepezil, Galantamine and Rivastigmine should only be considered as options in the treatment of people with moderate Alzheimer's Disease." This was a controversial decision as some people feel that these medicines should be available to people in the mild, early stages of Alzheimer's Disease.

If one of these medicines is started it is usual to review the situation after three months to see if it has made any difference. The best length of time to stay on medication is not known. Side-effects such as feeling sick, cramps and diarrhea may occur.

Memantine

This medicine is a relatively new medicine. It works by reducing the amount of calcium that gets into certain brain and nerve cells. This may help to slow down the damage to cells affected by Alzheimer's Disease. Like the medicines above, this is not a cure. Research studies show that it seems to slow down the progression of the symptoms in some cases.

As it is relatively new, the role of Memantine is not yet fully established. It is not routinely prescribed. In the same guidance as for the cholinesterase inhibitor medicines (above) NICE issued advice for the prescribing of Memantine. The advice states that "Memantine is only recommended as part of clinical studies for people with moderately-severe to severe Alzheimer's Disease."

Other medications :-

Ginkgo biloba is a herbal treatment. There is some evidence that this delays the progression of symptoms of Dementia in some people. More research is needed.

A tranquilliser is sometimes prescribed as a last resort for people with Dementia who become easily agitated.

An antidepressant may be advised if Depression is suspected. Depression is common in people with Dementia and may be overlooked.

A spirin and other medicines to treat the 'risk factors' for stroke and heart disease may be appropriate for some people. Especially those with Vascular Dementia.

Sleeping tablets are sometimes needed if difficulty sleeping is a persistent problem.

Support and care is the most important part of treatment:-

Most people with Dementia are cared for in the community. Often the main carer is a family member. It is important that carers get the full support and advice which is locally available. Support and advice may be needed from one or more of the following, depending on the severity of the Dementia and individual circumstances.

➙ District nurses who can advise on day to day nursing care.

➙ Community psychiatric nurses who can advise on caring for people with mental illness.

➙ Specialist psychiatric assessment. A GP can advise if this is needed.

➙ Social Services who can advise on local facilities such as day care centers, benefits, help with care in the home, sitting services, respite care, etc.

➙ Voluntary organizations. If you care for a person with dementia it is well worth getting information about the help that is available in your local area.

➙ The level of care and support needed often changes in time. For example, some people with mild Dementia can cope well in their own familiar home. Some may live with a family member who does most of the caring. If things become worse, a place in a residential or nursing home may be best. The situation can be reviewed from time to time to make sure the appropriate level of care and support is provided.

Many carers struggle on beyond the point that is appropriate. If you are a carer, you can ask a GP or district nurse to assess a person with Dementia if you feel that you need a greater level of support.

Other possible treatments :-

A. Reality orientation :- is thought to help in some cases. This involves giving regular information to people with dementia about times, places, or people to keep them 'orientated'. It may range from simple things such as having a board in a prominent place giving details of the day, date, season etc, to staff in a residential home 're-orienting' a person with Dementia at each contact.

B. Cognitive stimulation :- may help. This means 'stimulating the brain', for example, by recreational activities, problem-solving activities, and talking to the affected person. In addition, recreational activities enhance quality of life and well-being. If possible, including some regular physical activity such as walking, dancing, etc, may help to slow down the decline in mobility that is common in people with Dementia.

C. Reminiscence therapy :- may help in some cases. This involves encouraging people to talk about the past so that past experiences are brought into their current thoughts. It relies on long-term memory which is often quite good in people with mild-to-moderate Dementia.

D. Behavior management :- is sometimes tried to reduce depression in people who have depression in addition to dementia.

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