Dementia
Mom is getting forgetful and confused, should I be worried?
Introduction
Being forgetful is often accepted as a part of growing old, so much so that the phrase “senior moment” has been coined to describe lapses of memory encountered by older persons. Just when is it normal to be forgetful and when should we start getting worried?
While all of us invariably have occasional lapses of memory, such episodes shouldn’t hamper our ability to function normally. For example, we may occasionally misplace items or forget appointments. Some of us may also encounter moments when we wonder if we have locked the doors after leaving the office. Such episodes are usually largely benign and can occur when we are stressed, tired or otherwise distracted.
Warning signs
Certain situations do, however, warrant concern:
- if memory lapses occur with such frequency or are so severe as to be noticed by peers or family members,
- when memory lapses hamper one’s ability to function independently, or
- when lapses of memory compromise safety.
Examples of such incidents include forgetting to turn off the stove after cooking, leaving the front door wide open after going out or getting lost in what should be a familiar environment.
Fluctuating concentration or confusion also often indicate that something is amiss. For example, an older relative may suddenly start talking about meeting a relative who has passed away, or talk about wanting to do something that is totally incongruent e.g., going to school.
What are we concerned about?
Sudden or progressive changes in memory or behaviour are often encountered in older persons, in two situations that can potentially be serious, but which are often treatable.
The first situation is a state often described as delirium or “acute confusional state” and is characterized by fluctuating consciousness coupled with fluctuating confusion. Typically, the afflicted individual may wake up one day and start talking “nonsense” (e.g. seeing or hearing strange things) or they may start being unduly aggressive or suspicious. The affected person may also get into a state of hyper-alertness and not sleep for days, or be overly somnolent and remain drowsy or asleep for more than the usual time periods.
Delirium often indicates a serious underlying illness such as an infection, heart attack, heart failure or even a small stroke affecting strategic areas in the brain. It can also occur when a person develops adverse reactions to some common medications e.g. cough or cold preparations and medications given for heart failure or high blood pressure (diuretics).
The second situation that can account for progressive memory loss is dementia. Dementia becomes increasingly common with increasing age but should by no means be dismissed as being an inevitable component of ageing for which nothing can be done.Studies have shown that up to 10% of people who fulfill the criteria for the diagnosis of dementia actually have other conditions that are treatable and sometimes reversible. Beyond this, there are many aspects of dementia that are amenable to treatment and intervention that can improve the person’s outcome as well as his/her quality-of-life.
What is dementia?
Dementia is a term used to describe a group of conditions characterized by progressive loss of memory that is of such a severity as to interfere with a person’s everyday life. Persons with dementia often have other features reflecting the progressive nature of the disease process affecting the brain. These include difficulty communicating (e.g. being unable to find the appropriate words to communicate a thought), difficulty organizing one’s activities (e.g. being unable to prepare a favourite meal), or an unexplained inability to perform a simple routine (e.g. forgetting how to put on one’s clothes or take a shower).
Dementia is, however, not just about memory loss. There are other features of dementia that can be extremely distressing, both to the sufferer, and to their family members. These features are known as behavioral and psychological symptoms of dementia (BPSD) and include paranoid perceptions (e.g. the irrational fear that someone of trying to poison them or steal their things), agitation, depression, hoarding behaviour (e.g. keeping piles of rubbish or old newspapers for no apparent reason) or repetitive behaviour (e.g. repeatedly switching lights on and off).
Dementia is not a single disease, even though Alzheimer’s disease is often recognized as the commonest form of dementia. Other types of dementia include vascular dementia (dementia related to strokes), Lewy body dementia, fronto-temporal dementia, cortico-basal degeneration, just to name a few. The different types of dementia are due to different disease processes affecting different parts of the brain, and may have vastly different presentations.
What can the doctor do to help?
There is plenty that the doctor can do to help. Apart from recognizing the disease presentations and making the appropriate diagnoses through targeted assessment and investigations, there are medications that can be given to ameliorate the problematic concerns. If the symptoms are attributable to reversible conditions, treatment may be as simple as a change in medications or the implementation of treatment strategies to manage reversible conditions. If a diagnosis of delirium is made, the focus will be on managing the underlying condition that has precipitated the episode of delirium. For patients diagnosed with dementia, there are now medications available that can potentially retard the progression of memory loss in selected patients. Beyond this, there is much that can be done to manage the other aspects of dementia that are equally distressing (e.g. BPSD). Management strategies should go beyond the issue of medications and include counseling and the provision of resources to help the patients and their family members cope with the catastrophic diagnosis of dementia.
What we should NOT (and must NOT) do
When we encounter situations whereby our loved ones are suffering from sudden or progressive memory loss, there are two extremes of behaviour that must be avoided at all cost.
Firstly, we MUST NOT dismiss the problem as an inevitable part of ageing, for which nothing can be done.
Secondly, we MUST NOT assume that our loved ones have gone “mad” and immediately commit them to a nursing home.
Our knowledge and understanding of the process and problems associated with ageing have grown tremendously and there is much that can now be done to help patients who suffer from delirium and dementia. In addition, there is a need to recognize that suffering goes beyond the patients themselves – family members are often severely affected and under great stress. Resources are available to help care for the carers and improve the outcomes and quality of life for both patients and carers alike.
Contributed by Dr Sitoh Yih Yiow, Consultant Physician and Geriatrician
Age-Link Specialist Clinic for Older Persons (www.age-link.com)