What is dementia?
Dementia is a progressive brain dysfunction (in Latin 'dementia' means irrationality), which results in a restriction of daily activities and in most cases leads in the long term to the need for care. Many diseases can result in dementia, the most common one being Alzheimer's disease.

How common is dementia?
In our society of longer lifetime the probability of suffering from dementia increases with advancing age. Dementia predominantly occurs in the second half of our life, often after the age of 65 - some experts think that this is the 'price society has to pay' for our higher life expectancy and therefore the term 'dementia' activates similar fears and repression mechanisms as 'cancer' or 'AIDS'.
The frequency of dementia increases with rising age from less than 2 % for the 65-69-year-olds, to 5 % for the 75-79 year-olds and to more than 20 % for the 85-89 year-olds. Every third person over 90 years of age suffers from moderate or severe dementia (Bickel, Psycho 1996, 4-8). About half of those affected by dementia suffer from Alzheimer's disease.
About 5 % of people above 65 years of age, about 20 % of those over 80 years and about 30 % of those over 90 suffer from Alzheimer's disease.
The relatives share their fate with many people who are equally affected.



Types of Dementia:
Although Alzheimer's disease is the most common form of dementia there are other disorders that can lead to dementia. Vascular dementia, sometimes known as multi-infarct dementia, may follow a stroke. Like Alzheimer's disease, vascular dementia is progressive but the symptoms begin far more rapidly. Areas of the brain not affected by the stroke tend to remain unaffected and this contrasts with the more general deficiencies that accompany Alzheimer's. Having Alzheimer's does not prevent vascular dementia and it is quite possible to have both.
Pick's disease is a rare form of dementia that affects the frontal and temporal lobes of the brain. The clinical picture is fairly similar to Alzheimer's but differences can be detected at autopsy. Creutzfeldt-Jakob disease (CJD) has symptoms that often include spasms of the body. This disease is caused by a slow-acting virus that can live in the body for years before any signs of the disease become obvious. Once the signs of Creutzfeldt-Jakob disease become apparent its progress is rapid.
Huntington's disease is an inherited progressive form of dementia in which personality, memory and mood changes as the disease advances. Children of people with Huntington's have a fifty percent chance of getting the disease themselves. In its later stages severe twitches, spasms and involuntary movement of the limbs become apparent.
Parkinson's disease, a slow progressive neurological disorder, is marked by tremors, unsteady gait and rigidity. In older people the chances of Parkinson's disease leading to dementia is around 60 percent.
Infectious diseases such as HIV and AIDS, meningitis, advanced neurosyphilis and possibly a regular life-history of bacterial or viral infections may lead to dementia. Dementia is also sometimes associated with drug abuse or toxins such as mercury, carbon monoxide and lead.

What are the most important early indications of dementia?

1. Forgetfulness with effects at work:
Most people sometimes forget names or appointments. If this happens more frequently and inexplicable states of confusion also occur, this might be an indication for a decline in memory function.

2. Difficulties with familiar activities:
People who are very busy are sometimes absent-minded and for example forget the pot on the stove. People with dementia possibly not only forget the pot on the stove but also that they have cooked at all.

3. Language problems:
Most people sometimes experience difficulties in finding the right words. Dementia sufferers often cannot remember simple words and instead they use inappropriate fillers which makes it difficult to understand the sentences.

4. Problems with spatial and temporal orientation:
A lot of people sometimes forget e.g. the day of the week or they get lost in unfamiliar surroundings. Dementia sufferers might be in their own street and no longer know where they are, how they got there and how to get home again.

5. Impaired capacity of judgement:
People not always choose clothes suitable for the weather. Dementia sufferers sometimes wear totally inappropriate clothes. For example, they wear a bathrobe while shopping or several blouses on top of each other on a hot summer day.

6. Problems with abstract thinking:
For many people running a bank account is a challenge. Dementia patients can often neither recognise numbers nor carry out simple calculations.

7. Leaving things behind:
From time to time almost everybody leaves their keys or a wallet behind. Dementia sufferers however might put things in completely inappropriate places, such as for example the iron in the fridge or a watch in the sugar bowl. Afterwards they do not remember where they put them.

8. Mood swings and behavioural changes
Everybody has mood swings. People with dementia may have very sudden mood swings, often without discernible cause.

9. Personality changes:
With advancing age the personality of most people changes a little. People affected by dementia may experience a very pronounced personality change suddenly or over a longer period of time. Somebody who is generally friendly, for example, becomes unexpectedly angry, jealous or timid.

10. Loss of initiative:
Nobody continuously works with the same motivation. Dementia patients sometimes loose the zest in their work and the interest in their hobbies completely without enjoying new activities.

What are the stages of Alzheimer's dementia?
Alzheimer's disease can take very different courses. It is a slowly unfolding, progressive disease which is accompanied over time by changes in the appearance of the patient. The disease is typically divided into three stages. In medical terms, Alzheimer's disease is divided into mild, moderate and severe or early-stage, mid-stage and late-stage Alzheimer. The mild stage is typically characterised by impairments of mental abilities as well as mood swings. In the moderate stage, behavioural disturbances usually increasingly develop, whereas physical problems are dominant in the advanced stage. The individual course of the disease is, however, very variable.

Can dementia be treated?
There are a number of favourable conditions which can ease the situation of the patient and his/her relatives - these conditions concern in particular the actual care and the organisation of the environment. Improvements can be achieved through physical, emotional and also mental activation, for example with the help of physiotherapists or ergotherapists. These helpful approaches will be subject of the next units. There is even help for a number of physical problems such as incontinence, difficulties of food intake and problems of lying down.
In the early stage, training of thinking and memory functions should only be carried out carefully, otherwise there is the danger that the patient is always reminded of his/her diminishing mental abilities. This also applies to the formerly popular approach of reality orientation training.
As with numerous other diseases there is no cure for the illness but medication can improve disease symptoms. There are a number of drugs on the market today for improving brain function. Typically antidementia or psychotropic drugs are prescribed.

Diagnosis
Patients affected by dementia are usually not able to visit a physician on their own initiative. This is where the support of the relatives is important - their accounts can make the diagnosis easier. The physician will conduct a general physical and neurological examination in addition to documenting the medical history.
In addition a series of examination procedures are conducted involving psychometric tests, sometimes with questionaires or a few exercises. This serves to establish the extent of the difficulties. Part of such a neuropsychological examination is for example the Mini-Mental State Examination (MMSE) which is a commonly used test. This procedure can be a strain for the patient. During such examinations the problems become obvious and this can trigger shame and also despair (especially if the relatives are present and the problems have not previously been discussed). Empathy and substantial tact is needed in order to avoid the patient giving up.
The most important source of information are those people to whom the patient relates. The physician consults them concerning the medical history of the patient, similar diseases of relatives, the development of current symptoms, the limitations in dealing with everyday life and about possible behaviourial disturbances or dangers.
Part of the first examination include laboratory blood tests and possibly cerebral liquor tests. Some physicians also carry out electroencephalography (EEG) or imaging diagnostics such as computer or nuclear spin tomography (magnetic resonance tomography, MRT) which show the brain in layers or even in its function (for example positron emission tomography, PET).
It is important within the diagnostic framework that the relatives are well informed by the physician about the possible causes of the dementia and about the test results in order to obtain a satisfactory impression about the steps which have been undertaken. If a physician tries to put off relatives with words such as "this comes with age, is just a part of ageing", this is a very poor practice.
Everybody has the right to be informed of medical diagnoses: this is true even if the diagnosis is hard to take like for example cancer or AIDS. This might enable the patient to decide how to spend his/her time and to make his/her own decisions for the future. There are varied opinions in medical circles about disclosure of the diagnosis of dementia. Disclosing a diagnosis should always be followed by joint discussions about the next steps to be undertaken. The current point of view is that every patient, according to the stage of illness and to their personality has the right to know but also the right not to know. This results in a step by step procedure for the information process. The patient is given part of the information in a way he can understand and he is asked if he wants to know more. Informing the relatives always needs the consent of the patient.
It is a myth that ageing and psychiatric problems go hand in hand and it is also a myth that it is not worth conducting accurate diagnostics, because 'nothing can be done about it anyway' - some diagnoses are wrong, some diseases are treatable. If the situation is not satisfactory, relatives should seek expert consultation e.g in an Alzheimer advice centre, find out addresses of experts and obtain get information about legal/financial support, etc.

Treatment
There are a number of favourable conditions which can ease the situation of the patient and his/her relatives - these conditions concern in particular the actual care and the organisation of the environment. Improvements can be achieved through physical, emotional and also mental activation, for example with the help of physiotherapists or ergotherapists. There is even help for a number of physical problems such as incontinence, difficulties of food intake and problems of lying down.
In the early stage, training of thinking and memory functions should only be carried out carefully, otherwise there is the danger that the patient is always reminded of his/her diminishing mental abilities.
As with numerous other diseases there is no cure for the illness but medication can improve disease symptoms and can slow down the progression which can be considered a positive response to treatment. There are a number of drugs on the market today for improving brain function. Typically antidementia or psychotropic drugs are prescribed.
The more recent antidementia agents belong to the so-called acetylcholinesterase inhibitors (Reminyl (galantamine), Exelon (rivastigmine) and Aricept (donepezil)). Research suggests that the neurotransmitter acetylcholine is reduced in the brain of dementia patients; acetylcholinesterase inhibitors prevent acetylcholine being eliminated too quickly by a substance responsible for its breakdown. With these drugs the deterioration of the symptoms can be delayed. The most recent development differs not only because of involving another mode of action but also because it could be shown in clinical trials that the deterioration of the disease could be delayed by at least 12 months. Apart from preserving and partially improving mental capacities and coping with daily activities, a delayed onset of behavioural disturbances and a reduction in caring time could also be demonstrated.
Psychotropic drugs can be used as a supportive therapy in the treatment of behavioural problems in dementia. There is often criticism particularly of these agents that they are only used to quieten patients down so that they only behave in an apathetic manner and cannot take part in daily events. It is however overlooked that to date the only drugs available were indeed effective but influenced patients in a negative fashion (as described above) because of other side effects. Recently, however, substantial progress has been made in the therapy of disturbed dementia patients. Physicians can now treat these patients effectively without patients dosing during the day and wandering around at night.
Apart from treating the specific symptoms of Alzheimer' disease, it is important to observe the general state of health because a good general condition improves the feeling of well-being. An increasing degree of confusion can be caused by a physical illness and restlessness and aggressive behaviour can be connected to pain.

Sailesh Mishra
sailesh2000_2000@yahoo.co.uk