Dementia is a condition that usually affects older adults. The two common types of it are Alzheimer's disease and Vascular Dementia. Whilst the loss of memory or forgetfulness is commonly associated with Dementia other factors must also be considered. We had a chat with Dr Shehan Silva, Consultant Physician/ Geriatrician regarding Dementia and his advice for families with Dementia patients. 

Q WHAT IS DEMENTIA?
Dementia is a commonly associated condition which affects primarily older adults. This condition results in a gradual decline in higher functions of the brain. Higher functions of the brain include memory, language skills, mathematical and logical skills and personality.

Q WHAT ARE THE DIFFERENT TYPES OF DEMENTIA?
There are several types of Dementia. The two common ones are Alzheimer's disease and Vascular Dementia. In
Alzheimer's disease there is a gradual decline of the higher functions due to the deposition of certain proteins in the nerve cells of the brain which results in an action similar to suffocation of the same. Vascular Dementia results from multiple factors such as high blood pressure, diabetes, and high cholesterol levels acting singularly or in concert just like strokes or heart attacks. Therefore, it is essential that those factors are well controlled to prevent or slow down the process of development of Vascular Dementia.

Parkinson's disease may also give rise to Dementia which is associated with abnormal movements (tremors and
slowness) and visual hallucinations. Dementia is usually a disease which is progressive and cannot be completely cured or reversed although it can be slowed down with control of distress. There are however some conditions such as low thyroid hormone states and certain vitamin deficiencies like vitamin B12 which are completely curable.

Q WHAT TESTS IF ANY CAN BE DONE TO DIAGNOSE IT?
When a person or a loved one realises that there are problems regarding higher functions of the mind it is crucial that he meets an elderly care specialist, neurologist or psychiatrist to arrange certain cognitive tests to
detect the presence of Dementia. These tests are sort of puzzles or mental state examination tests. Some of the examples include the Mini Mental Score Test (MMSE), Montreal Cognitive Assessment (MOCA), Mini-COG and Addenbrookes Cognitive Examination (ACE-III).

Q WHAT ARE THE INITIAL SIGNS OF IT?
The subtle manifestations of Dementia include gradual loss of memory and computational skills. Although with age there may be subtle memory issues such as forgetfulness of names. However, if there are marked
problems such as forgetting crucial elements such as forgetfulness of certain activities that they completed such
as what they had for a meal or even financial matters, they may herald the presence of Dementia.

Other symptoms include certain behavioural changes such as inappropriate disposition (clownish behaviour, aggressiveness, undue anxiety, sexual inhibitions etc.)

Q WHAT ADVICE WOULD YOU GIVE TO FAMILIES TAKING CARE OF A DEMENTIA PATIENT?
It is essential that people who have traits of Dementia are evaluated properly by a clinician. Once a diagnosis is reached the disease progression can be modified by control of risk factors and commencement of medication. The targeted medication includes drugs such as Donepezil, Memantine or Rivastigmine which need to be commenced early after appropriate selection by a doctor.

Furthermore, the contributory medical factors mentioned need to be addressed by appropriate drugs as well as lifestyle modification. Within the family, the patient needs to be taken care of patiently and with consideration. The forgetfulness should not be stigmatised or patronised by loved ones but always be corrected or explained lovingly. All family members should assist their loved ones to realise that the forgotten thing is remembered. There may be a repetition of this forgetfulness which needs to be patiently dealt with.

Q WHAT TYPE OF ASSISTANCE SHOULD BE GIVEN?
Invariably as time goes patients with Dementia will have a decline in their activities of daily living. These include basic activities such as toileting, washing, grooming and eating, or instrumental activities such as money matters, telecommunication and mobility outside the home. It will come to a point that they will need assistance at a dedicated level with greater demand. Although patients will need a small amount of help initially, at advanced stages a one-to-one dedicated caretaker will be necessary. It is essential that patients are provided assistive mechanisms such as large visible clocks/ calendars, and large readable whiteboards to assist in remembering
important things, use of electronic devices with alarms to alert them to accomplish tasks etc.

Patients with dementia need to engage in mind-stimulating activities such as colouring, puzzles, reading books/
watching appropriate entertainment and listening to music. They should also engage in activities such as senior citizen groups in churches, temples and communal residencies. They need to be in the decision-making processes of the family as well. More importantly, love and understanding are essential and all condescending and abusive behaviour including anger should be void at all times.

Q ARE THERE ANY SAFEGUARDS THAT YOU HAVE TO FIT INTO YOUR HOMES?
We hear of patients who may wander out of their homes without being able to find their way back or being subjected to circumstances such as theft and injury. It is essential that the doors and gates are kept secure and
that there is vigilance about the activity of demented individuals kept at a higher level. Furthermore, certain people such as those with Parkinsons' Disease or normal pressure hydrocephalus may have mobility issues and
unstable posture causing them to have a risk of falls and bad consequences such as strokes. It is imperative that the house is made safe by removal of clutter, ensuring good lighting, safe surfaces which are not slippery (especially washrooms) and removal of free-lying unsafe objects such as sharps, poisons etc.

Q HOW DO YOU DEAL WITH THE AGGRESSION OF THE PATIENT? WHAT ABOUT THINGS LIKE NOT WANTING TO BATHE? THE PATIENT’S REFUSAL TO EAT? THE PATIENT’S REFUSAL TO TAKE MEDICINE?
Invariably patients with advancing Dementia would have behavioural changes such as aggressiveness, extreme sadness, fearfulness, poor sleep, refusal of important things such as eating and bathing, and inappropriate behaviour (e.g. sexual inhibitions, faecal and urinary soiling). This is known as Behavioural and Psychological Symptoms of Dementia (BPSD). Just as the medical conditions need to be kept under control along with regular administration of Dementia medication, BPSD also may need certain antipsychotics.

Loved ones need to discuss this with their doctor and see which agent will be better at controlling them. Over-counter medications including irrational use of sedatives or sleep pills are discouraged. Furthermore, all such behaviour should be addressed patiently. In a difficult patient rather than enforcing them to engage in the desired
activity immediately, they should be approached at a later time with a different and canny approach in a non-patronising and non-threatening manner. With regards to meals, small frequent meals which are novel and are appeasing should be tried. Medication if they are in large quantities can be spaced out rather than be given en masse. It is essential that the well-being of carers' loved ones and the rest of the family is ensured. Caregiver
aggression and depression are most of the time undetected. There should be breaks and release of duty of carer so that they will not be continuously exposed to difficult demented patients. Please speak to the clinician regarding this.

Q WHAT ARE THE NECESSARY CHECK-UPS?
As mentioned before, it is essential that patients who have traits of Dementia are seen by a clinician and assessed with regard to cognition.