Understanding Dementia In The Elderly

Dementia is defined as a decline in mental abilities (cognition), which can affect one's ability to execute tasks and interact with people and the environment. Symptoms of dementia can include: difficulty remembering names, people and past events, impaired speech and language skills, difficulty with self-care abilities, periods of confusion, diminished insight and judgement, and poor safety awareness. Symptoms of dementia can also include a change in personality, increased agitation, psychosis and delusional thinking.

Dementia used to be called 'senility', but that term is not widely used now. Dementia includes a broad spectrum of disorders which can cause mental decline in older people. This can include vascular dementia, multi-infarct dementia, Lewey body dementia, Frontotemporal dementia, and of course Alzheimer's dementia (AD). AD is the most commonly diagnosed dementia in people over 65 years of age. People with other primary disorders, such as Parkinson's or stroke, may also develop some form of dementia at some point.

The brain is a very complex organ and much is still unknown regarding how the human brain processes information. We do know that different types of memory are stored in different parts of the brain, and the brain needs to work in a highly coordinated manner in order to efficiently store and retrieve information. Chemical neurotransmitters are the mechanism by which signals are transmitted in the brain. These chemicals include acetylcholine, gaba, dopamine, serotonin, melatonin, and some others. Most cognitive medications seek to balance out one or more of these chemical neurotransmitters. And although depression and psychosis are treated with different medications, these can often help stabilize the underlying dementia symptoms.

Dementia can be categorized as either mild, moderate, or severe. (Although, it can sometimes be more accurate to assess dementia symptoms on a 1-10 sliding scale, as mental health deficits are often too complex to assign a category.) Each stage of dementia will present it's own set of obstacles and health issues for the client and caregiver. For example, the person may still be continent during the early stages of dementia, but may latter become incontinent and unaware they are voiding, once the disease has progressed. A senior with mild dementia may still be driving their automobile, but once the disorder has progressed, then driving would no longer be appropriate.

Whenever dementia is suspected, a thorough neurological and physical examination is vital. A neurologist who specializes in geriatric assessments should be consulted. They would be able to provide the client and family important information on the diagnosis and prognosis. And they would be able to answer any questions in regards to medications, etc. Often, medication will be prescribed and these should be monitored by the family for effectiveness and side effects. These need to be given at a specific time each day and at a certain dosage in order to be effective. What may work for one person with dementia may not work for another, and a change of dosage or type of medication may at some point be needed, if deemed ineffective.

There has been a lot of progress in understanding AD, and some newer medications approved by the FDA are producing good outcomes for people with dementia; such as the drug Namenda. Although cognitive medications can often help to stop the progressive decline and stabilize the individual for a period of time, they should not be viewed as a cure; as dementia is a progressive disorder. There has been some recent research which showed that people with mild to moderate AD can still learn new tasks and retain information; and this usually requires daily routines that are structured and in a stable environment, along with the proper medication.

A small pet can make a good companion for someone who has dementia; and who may lack adequate social skills and have little interaction with other people.

Some of the important cognitive components which we rely upon to function in life:

1. Level of Arousal
2. Orientation
3. Recognition
4. Attention Span
5. Initiation of Activity
6. Termination of Activity
7. Memory
8. Sequencing
9. Categorization
10. Concept Formation
11. Spatial Operations
12. Problem Solving
13. Learning
14. Generalization
15. Judgement
16. Safety Awareness

'Executive function' refers to our ability to integrate these cognitive components in order to perform a series of actions, which will produce a desired outcome. For example, baking a cake would require knowing which ingredients are needed and gathering them together, reading and following directions, using the correct baking utensils, measuring and combining the ingredients together in the proper amount, preheating the oven, baking at the correct temperature for a specific amount of time, safely removing the cake from a hot oven, making and then applying the frosting. Someone with dementia would have difficulty with one or more of the steps required to perform this task appropriately.

Because people with cognitive deficits may decline in their ability to safely function in the home environment, the Occupational Therapist will need to address these issues with the client, family and caregiver in order to help the person remain safe and as independent as possible.

Some of the other subtle cognitive issues which can affect a senior's ability to function include 'low frustration tolerance', where the person quickly loses their temper and gets frustrated when they are not able to do things correctly or as easily as they used to; and 'mental inflexibility' where the person is unwilling to accept that things can be done another way, as "this is the way I have always done it", and they rigidly hold onto this way of thinking, even when they can no longer safely perform the task.

When mental abilities have diminished, seniors are also at a much greater risk for declining physical health. This can include an increased risk for falling, not taking prescribed medications daily, not eating balanced and healthy meals, a lack of proper hygiene and grooming, inability to handle emergency situations, etc.

Case Study: A client with dementia has a recent history of falling and the spouse is concerned that he can no longer care for her adequately, but does not want her to go to a nursing home yet. The biggest issue seems to be the client's impulsivity, getting up and walking without using the walker and then falling or losing her balance. Other self-care needs are being adequately addressed with the spouse's help.

It was agreed to try a chair alarm to let the spouse know when she was standing up without supervision. When the client hears the alarm, she knows that it is not safe, and this will also alert the spouse if he is not in the room. The living room furniture was also rearranged so that should the client stand without supervision, then there would be something nearby for her to hold onto. A bed alarm is also being used to alert the spouse if the client should attempt to get out of bed without assistance. A bed rail was also added to help with the client's safety getting in and out of bed. The spouse was encouraged to provide more opportunities for walking with the client. He was also willing to have a home health physical therapist come in three times each week to help improve her strength, balance and endurance.

Caregiver Tips For Dementia

• It is important that the individual have a caregiver look after them, and to also make sure that a proper diagnosis is obtained and that sufficient medication is provided. If there is no family member, then maybe someone from their local church or community can be entrusted to help. Also, the local Adult Protective Services can have someone look into their well being, if there is no family member who is responsible for them.

• Have meals-on-wheels provide at least one meal each day. This can ensure that some proper nutrients are provided.

• A local home care agency can provide a ‘house sitter’ to stay with the person each day and help out with daily chores. They are available for as many hours as needed. This can get expensive, but a lower rate can sometimes be given when they are employed for a certain amount of hours each week.

• Have medications dispensed from a daily pill organizer. This way someone can make sure that each day’s medications are taken. Daily phone calls from someone familiar with the person can then check up on them and remind them, if they live alone.

• If the person is becoming incontinent, have them wear snug fitting disposable briefs with elastic leg bands. This will prevent accidents from ruining clothing. Have them on a toileting schedule of every two to three hours during the day. At night a wet alarm on the mattress can be used to remind the person to change out of wet clothing.

• Provide plenty of physical activities, such as daily walks to keep up their strength and endurance. It has been shown that daily walks provide mental stimulation as well.

• Have the person participate in mentally stimulating activities daily; such as board games, card games, word puzzles, etc. Tasks that require interaction and a bit of problem solving. Watching television is the least stimulating for those with dementia, but sometimes that is all they wish to do. The problem with television is there is no interaction or response required from the viewer, which is the same issue with young children. The person needs to be engaged with the environment in order for it to be sufficient as mental stimulation.

• Some people with dementia enjoy using their hands and holding on to items; things that can be manipulated, etc. For a retired mechanic, maybe nuts and bolts could be used; for a housewife who enjoyed sewing or knitting, maybe a ball of yarn could be used. There is no limit to what can be tried; as long as the items are not sharp, not swallowed easily, breakable, etc.

• Be aware that those with dementia often become more agitated in the late afternoon, and they should not be over-stimulated during this time frame. Sometimes a nap will help calm them. Even a change in medication intervals can help keep them calm in late afternoon.

• Be aware that medications can affect their level of arousal. Let the physician know about any side affects that are impacting the person’s ability to function. Drug levels need to be at a certain level (titrated) in order to be effective. Too little medication will not help them and too much can cause undesired side affects.

• Consider joining the local chapter of the Alzheimer’s Association. They are a great resource for clients and their caregivers.