Evaluation of and Caregiving for Someone with Dementia
For the average person, determining if a friend or love one has a minor or a serious memory problem is difficult. Even as an experienced professional, making the correct diagnosis is often complicated. To make understanding the illness easier, it is necessary to distinguish what is normal memory loss and when do those changes mean something more serious. One way to determine the severity of dementia, in particular Alzheimer's Dementia (AD), is to separate it into stages, such a Barry Reisberg and associates did (summarized from Kaplan and Sadock's book on Clinical Psychiatry.) With this staging, it is easier to see if a person has a problem, how severe it is and it gives one some idea of what interventions may be helpful for that person.
Stage 1- Normal with no noted losses. This constitutes about 20-40% of people over 65.
Stage 2- The individual may note problem's with names and loss of objects.
Stage 3- Mild impairment observed by others: becoming lost in unfamiliar surroundings, decreased performance in work, word and name finding problems, concentration problems, a tendency to forget what is said and to repeat oneself. This may be early dementia, but may be the result of the normal aging process.
Stage 4- Mild Dementia with clear deficits in concentration, memory, orientation to time and place, and loss of capability to function at work and at other tasks.
Stage 5- Moderate dementia with deficits large enough to prevent the person from living independently in the community without assistance. At this stage, recall of major aspects of one's life is impaired. They may not be able to recall who is the President, what year it is, and have difficulties in simple math. Depression, sleep, appetite, anger or behavior problems may arise. Support with living is usually required and nursing home placement may be necessary.
Stage 6- Moderately Severe Dementia with the person requiring constant assistance. They may not remember the name of their spouse, where they live, past events, and even counting backwards from 10. Problems with toileting may occur. Emotional and behavioral problems become more prominent. Agitation, anger, sleep disturbance, negative thinking, and violence can occur.
Stage 7- Severe Dementia with serious losses in the areas of speech, walking, and daily tasks, such as feeding, dressing, bathing, and toileting.
Dementia can be divided into several types: Alzheimer's dementia (AD), Vascular, Lewy body, Frontotemperal, Huntington's, Alcohol induced, and others. The cardinal feature of AD is its slow and progressive nature of mental deterioration. Vascular dementia is the results of strokes, small or large to multiple areas of the brain. In this dementia, the loss of mental functions occurs in a "stair step" fashion with an sudden loss, then a relatively stable period, followed by subsequent losses as further strokes may occur. People developing vascular dementia often have a history of heart disease, high cholesterol, diabetes or hypertension which may be a factor in the vascular disease to the vessels in the brain. The other dementias are less common and a little too complicated to describe here.
In handling a person with developing Alzheimer's disease, once the diagnosis is made, it is important to know the illness is progressive. Vitamin E on a daily basis may be helpful, but some think it may have to be in the form of leafy green vegetables and not just as a capsule. Certain medications called Acetylcholinesterases (Aricept, Exelon, and Reminyl) have been shown to slow the development of the disease. They work to increase the amount of acetylcholine in the brain. It is this loss that is believed to be the cause of AD. These medications if helpful may delay AD's symptoms from occurring by about 6 months, for example, on the average, a person placed on one of these medications will remain out of a nursing home for 6 months longer then if they had not been placed on the medication.
As improving Acetylcholine in the brain helps a person with dementia, impairing acetylcholine will worsen their mental state. Medication that may cause this are called anti-cholinergic medications. These include most anti-histamines (except Allegra and Claritin), most over-the-counter sleeping medication (including Tylenol PM and others), certain Gastrointestinal and bladder medications (Bentyl, Detrol, Tagament), medications for dizzyness (Antivert/Meclazine), and some Parkinson medications. Anticholinergic medications should be avoided in dementia patients were ever possible.
With vascular dementia (VD), it is important to reduce the factors that may cause further strokes which may include improving they blood sugar and blood pressure, dealing with cardiac arrhythmia, lowering fats and cholesterol, and if necessary thinning the blood to prevent further blood clots. In VD, the specific losses and time course of the illness is unpredictable since the stokes occur at any time or in different parts of the brain.
In conclusion there are a few things I tell the caregivers of people with dementia. Contrary to the way it may seem, a person with dementia should not be encouraged to use their thinking and decision powers. Dementia patients, especially those with moderate or worse AD, if put into decision making situation or questioned about their memory will become stressed. When stressed, their mental abilities for a period of time are more impaired. Taking such a person to eat at a buffet can overwhelm them. There are just too many choices. It is best if you make the decisions for them instead of asking them to make the decisions.
And when they don't remember what seems to be a simple thing, or states something that isn't true, don't confront or correct them at that point. Instead, wait a short while and then in a subtle way present the information as part of a conversation, telling them about who has visited, where they are and what day it is. For example say, "Can you believe it is already July?", where earlier she had said she thought it was December. Amazingly, many dementia patients will take these cues and sustain them for a while.
Finally, it is important for a person with dementia to keep very steady routines. They lose a lot of the motivation for and internal guidance of routines such as sleeping, eating and activities. If they aren't encouraged and at times held to specific routines, they will become disorganized in their daily activities.
The elderly in general don't need more then eight hours of sleep. If they try to sleep more then that, they risk being unable to sleep at night. Either way, I feel it is important that the elderly, and people in general, awake at the same time every day, and remain out of bed from the time they awake for the next six hours. Having a nap after lunch is not a problem as long as sleep during the night doesn't become fragmented. If it does fragment with frequent nighttime awakenings, then lessening the time in bed may be needed.