Dementia and Alzheimer's Disease

What Are Dementia and Alzheimer's Disease?

Dementia is a collective term used to describe neurodegenerative disorders of the brain that affect cognition. It is estimated that over 55 million people around the world have dementia. Alzheimer's disease is the most common type of dementia (60-80% of cases) and affects 6.7 million Americans. In people with dementia, the impairment in cognition is different from the memory problems associated with normal ageing. Dementia can impair their ability to take care of themselves and their daily affairs.

In a person with dementia, the neurons in the regions of the brain that affect cognition progressively get damaged. Dementia is a clinical diagnosis made in individuals with a significant decline from their baseline level of cognitive performance. The decline can occur in one or more cognitive domains, including:

  • Memory, including the ability to remember recent events and conversations.
  • Learning new information and applying it.
  • Ability to sustain attention on complex tasks.
  • Language includes naming, speaking without grammatical errors, and using appropriate words.
  • Movement-related skills, including hand-eye coordination, body-eye coordination, and visual-auditory skills.
  • Ability to focus attention, plan, organize, and coordinate multiple tasks.
  • Ability to perceive, understand, and judge others and one's social behaviour.

The severity of the cognitive impairment can be quantified through a neuropsychological assessment or a clinical assessment. For a diagnosis of dementia, a person's cognitive issues should be severe enough to affect their ability to perform their daily activities independently. This includes their ability to manage their finances and medications, dress appropriately, and maintain hygiene. The cognitive impairment should not be the result of another psychiatric disorder like depression or schizophrenia or medical conditions like delirium (a temporary state of confusion occurring over a short time due to underlying medical conditions, medications, substances, or toxins).

There are different types and causes of dementia. The most common types of dementia are:
  • Alzheimer's disease: the most common type of dementia. Alzheimer's disease usually begins with lapses in memory for recent events, conversations, names, or faces.
  • Vascular dementia: the second most common type of dementia. This type of dementia is caused by strokes or mini-strokes (also known as transient ischemic attacks). Each stroke or mini-stroke can cause problems in the blood supply of the brain. Individuals with vascular dementia have a progressive decline in cognition with each stroke or mini-stroke. The symptoms depend on the area of the brain being affected.
  • Dementia with Lewy bodies: in individuals who have dementia with Lewy bodies, the main symptoms include hallucinations; sleep disturbances like nightmares; appearing sleepy or tired; and trouble with movements or balance like falls, tremors, slow movements, and difficulties in walking. Problems with memory usually occur later in the progression of the disease compared to Alzheimer's disease.
  • Frontotemporal dementia: in frontotemporal dementia, individuals can experience personality changes (such as lack of interest or emotions and impulsive anger) and difficulties in organizing and planning daily activities like going to work and paying bills. They can also struggle with language, like difficulty naming things, making grammatical errors, using inappropriate words, and maintaining fluency of speech. Problems with memory usually occur later in the progression of the disease compared to Alzheimer's disease.

Individuals can have dementia caused by more than one factor. This is called mixed dementia. Dementia can also be caused by other medical conditions, including traumatic brain injury, use of alcohol and other substances, HIV infection, Parkinson's disease, and Huntington's disease.

In the initial stages of dementia, individuals may be able to work, drive, cook, and participate in their other daily activities with the help of friends and family. The progression of dementia and the abilities affected varies among individuals. As the disease progresses, they become increasingly dependent on their friends and family members to take care of their daily needs, like paying bills, buying groceries, and personal care, including bathing and dressing. They can also experience changes in mood, anxiety, paranoia, hallucinations, agitation, inappropriate sexual behaviours, and sleep disturbances. Individuals may wander from home and get lost or make mistakes while driving or cooking. This can cause significant concern for their safety. As the disease progresses to other parts of the brain, individuals with dementia can have problems with balance, falls, and swallowing. They may also eventually become bed-bound, requiring around-the-clock care.

Treatment

Currently, no treatment can reverse the disease process of dementia. The U.S. Food and Drug Administration (FDA) has approved medications to slow down the progression of Alzheimer's disease (but not other types of dementia). Some of these medications belong to the class of medications called cholinesterase inhibitors, which are prescribed for mild to moderate Alzheimer's disease [Aricept® (donepezil), Exelon® (rivastigmine) and Razadyne® (galantamine)]. One medication, Namenda® (memantine), has been approved by the U.S. FDA for treating moderate to severe Alzheimer's disease. In 2021, Aduhelm® (aducanumab) was approved by the U.S. FDA for treating Alzheimer's disease. Several new medications are also being studied to target various processes related to dementia with the goal of one day developing medications that can stop or slow down the cognitive decline of dementia.

Maintaining a healthy lifestyle can help prevent dementia from getting worse. Healthy lifestyle choices can include eating a balanced diet, being physically, socially, and mentally active, stopping smoking, cutting down on alcohol consumption, getting regular health checkups, and getting treatment for heart disease, hypertension, and diabetes.

Individuals with dementia can also have related conditions like depression, anxiety, agitation, and psychosis. Primary care providers or mental health providers can help manage these conditions with psychiatric medications, non-pharmacological interventions (such as addressing the cause of distress in the patient), or lifestyle changes (like maintaining an appropriate sleep-wake cycle). Behavioural therapists who have specialized in the care of dementia can use therapies like reminiscence therapy, validation therapy, reality orientation, and cognitive stimulation therapy to alleviate distress and related behaviours, provide comfort, and avoid boredom or loneliness.

Individuals with dementia may have difficulty identifying or explaining their needs. Recognizing and addressing their needs (e.g., pain, hunger, constipation, infections, skin rash, ingrowing nails, full bladder, and appropriate room temperature) can help an individual become comfortable and decrease the risk of behavioural problems. A calm and non-stimulating environment can be helpful, especially for sleeping at night. When the individual is anxious or agitated, redirecting their attention can be helpful. Instructions should be provided and broken down at each step, as individuals might have difficulty comprehending complex instructions. It is best to avoid being argumentative or confrontational with individuals with dementia, as they might not remember or understand the issues.

As the disease progresses in severity, the medications used to treat dementia or related behaviour problems can become less effective. After discussing the risks versus benefits of the medications with the treating clinician, they can be discontinued to reduce the burden of taking inappropriate and unnecessary medications.

Caregiver Stress

Caring for individuals with dementia can be very stressful for family and friends, especially as the severity of dementia progresses and caregivers spend more effort and time caring for the individuals. Caregivers can struggle with accepting the severity of dementia or become angry and frustrated. As caregiving takes more time and energy, the caregiver can become socially isolated and lonely. They may experience anxiety, depression, and sleeplessness as they worry about the care of the individual with dementia and their future. The chronic stress of caregiving can also have a toll on the physical health of caregivers.

It's important for caregivers to take care of themselves and to seek help when needed. Caregivers should find time in the day for themselves to pursue activities that they enjoy, relax, and exercise. They should ask for help from family and friends to take turns caring for the individual with dementia. Respite care or adult day care centres can also be considered (see the U.S. Administration on Aging's Eldercare Locator). Caregivers should also try not to take problematic behaviours of individuals with dementia personally, as they are symptoms of the disease.

Caregivers should consider psychotherapy/counselling or see their mental health provider if they feel anxious or depressed about caring for their loved ones. Attending caregiver support groups for individuals with dementia can also be helpful. Information about caregiver support groups and other caregiver resources can be obtained from local chapters of the Alzheimer's Association.

Suppose the care for the individual with dementia is beyond the caregiver's capabilities. In that case, long-term care facilities like assisted living facilities or memory care centres should be considered as they have nursing staff skilled in the care of individuals with dementia.

Source From psychiatry.org 

FAQs

Many people experience problems in memory or cognition due to the normal physiology of ageing. However, compared to the memory and cognitive issues of dementia, age-associated memory impairment does not affect the activities of daily life, our ability to complete our tasks, or our ability to learn new things.

On clinical assessment, if an individual is found to have impairment in cognition and memory that is more than expected for age but is severe enough to affect their daily living, they are diagnosed to have a mild neurocognitive disorder or mild cognitive impairment (MCI). Individuals with MCI are at high risk of developing dementia, and they need periodic assessment by a primary care provider or mental health provider to assess the progression of the cognitive impairment.

The symptoms of dementia vary between individuals and types of dementia. Some of the early signs include memory problems, problems with language, misplacing personal belongings, trouble with organizing and planning activities like physician appointments, mood changes, difficulties in performing familiar tasks or using everyday objects like a cell phone, being confused about time and place, and withdrawal from social activities like family gatherings.

Only a few rare subtypes of dementia run in families. These rare familial types of dementia are caused by mutations in genes inherited by family members. These types of dementia usually manifest before the age of 65. Genetic testing for these types of dementia is not recommended, as a positive test does not necessarily mean that an individual will develop dementia. Even with a history of multiple family members with dementia and a positive genetic test for a familial type of dementia, an individual may not still develop dementia. There are no specific preventative measures for dementia. The risk of developing dementia can be reduced by making healthy lifestyle choices such as:

  • Eating a balanced diet.
  • Avoiding tobacco or other substances.
  • Limiting the consumption of alcohol.
  • Being physically, mentally, and socially active.

Unfortunately, there is no treatment yet that can reverse the disease process of dementia. Medications approved by the U.S. Food and Drug Administration (FDA) can slow down the process of Alzheimer’s disease (but not other types of dementia). As the disease progresses in severity, the medications can become less effective, and they can be discontinued to reduce the burden of taking inappropriate and unnecessary medications. New medications are being studied now with the hope that they will one day be able to slow down or stop the decline in cognitive impairment.

Stress and burnout are common in caregivers for individuals with dementia, especially as the severity of dementia progresses and requires more investment in care by caregivers. Caregivers can be frustrated, depressed, and anxious about caring for their loved ones, which can take a toll on their physical and mental health. Caregiver burden and stress must be addressed when assessing individuals with dementia. They should be provided with a break from caregiving for a few hours a day to take care of themselves and their needs. Family members can also take turns providing care for the individual with dementia. Caregivers are encouraged to seek psychotherapy and counselling if they feel anxious or depressed about caring for their loved ones. Information about caregiver support groups and other caregiver resources can be obtained from the local chapter of the Alzheimer’s Association.

Source From psychiatry.org 

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