Dealing with Dementia

A Guide to Alzheimer's Disease and Other Dementias

By Brian Draper

Allen & Unwin

Copyright © 2004 Brian Draper
All rights reserved.
ISBN: 978-1-86508-853-2

Contents

List of illustrations,
List of tables,
Preface,
CHAPTER 1 WHAT IS DEMENTIA?,
CHAPTER 2 PREVENTION OF DEMENTIA I,
CHAPTER 3 PREVENTION OF DEMENTIA II,
CHAPTER 4 THE SYMPTOMS AND COURSE OF DEMENTIA,
CHAPTER 5 TYPES OF DEMENTIA,
CHAPTER 6 DEMENTIA ASSESSMENT,
CHAPTER 7 DRUG TREATMENTS,
CHAPTER 8 PSYCHOSOCIAL TREATMENTS,
CHAPTER 9 FAMILIES AND OTHER CARERS,
CHAPTER 10 COMMUNITY CARE SERVICES,
CHAPTER 11 RESIDENTIAL CARE,
CHAPTER 12 ETHICAL AND LEGAL ISSUES,
CHAPTER 13 THE FUTURE,
Appendix 1 Australian telephone helplines,
Appendix 2 Websites,
Appendix 3 Books for carers,
Glossary,
Notes,

CHAPTER 1

WHAT IS DEMENTIA?

We live in an ageing world. Over the last century life expectancy in Australia has increased from around 55 years to 81.3 years in women and from 52 years to 75.6 years in men. With more people living beyond their allotted 'three-score and ten' years, age-related conditions including osteoarthritis, osteoporosis, cataracts, stroke, cancer, coronary artery disease and dementia have increasingly impacted upon the health of our community. Of these conditions, dementia is the condition that evokes the greatest fear in those contemplating the prospect of a lengthy old age. The possibility of becoming mentally incompetent, forgetful and dependent, in other words senile, can be very disturbing.

DEFINING DEMENTIA

First, let me clarify a few terms. 'Dementia' is a term used medically to describe a syndrome (set of symptoms) that is caused by many different diseases. These include Alzheimer's disease, vascular dementia and dementia with Lewy bodies. An analogy is the term 'cancer', which is used to describe any malignant tumour but is not itself a specific disease. The answer to the frequently posed question 'What is the difference between Alzheimer's disease and dementia?' is that, in a sense, there is no difference — Alzheimer's disease is one of the many different types of dementia.

The dementia syndrome is defined as an acquired decline in memory and thinking (cognition) due to brain disease that results in significant impairment of personal, social or occupational function. Other brain functions that are affected include orientation, comprehension, calculating ability, learning capacity, language, judgement, reasoning and information processing. While there are some notable exceptions, as I discuss later, dementia is usually of gradual onset and progressive. The World Health Organization (WHO) guidelines recommend that these symptoms and impairments be evident for at least six months before a confident diagnosis can be made. While most dementias are currently irreversible, this does not mean that dementia is untreatable. Its progression (course) can often be influenced and many symptoms can be ameliorated. As I discuss in later chapters, major advances have occurred over the last decade in this area.

Most dementing illnesses are progressive, and early symptoms and problems differ markedly from those in later stages. This may simply be a matter of degree — for example, mild memory impairment moving to profound memory impairment. Other symptoms and problems usually develop later in the course of the illness, urinary incontinence being one example. While it is customary to describe dementia in stages, there is overlap between stages and it may not always be easy to state precisely which stage a person has reached. The first stage is a 'pre-dementia' stage, also named by some researchers 'mild cognitive impairment'. Currently we are unable to identify accurately and reliably what it constitutes. The next three stages, as commonly described to carers during a diagnostic assessment, are 'early' or 'mild', 'moderate' or 'middle' and 'late' or 'severe' dementia, respectively. The final stage, 'advanced dementia', is usually found only in nursing home residents. The stages should be regarded as a guideline rather than as a sacrosanct statement about the person's progress (see Table 1.1).

HOW DOES DEMENTIA DIFFER FROM NORMAL AGEING?

Unlike dementia, the concept of normal ageing is poorly understood. Many of the accompaniments of ageing that result in disabilities in recent times have become treatable, which challenges the notion that they are inevitable features of the physiological ageing process and suggests that they may be considered pathologic conditions. Efforts to characterise mental changes intrinsic to normal ageing are fraught with difficulty, with terms such as 'benign senescent forgetfulness', 'age-associated memory impairment' and 'age-associated cognitive decline' being used and now generally reflect the extremes of normal ageing rather than describing a precursor of pathologic ageing.

We acquire knowledge through an active cognitive processing of information that involves thinking, learning and remembering; it is known as fluid intelligence. Fluid intelligence tends to decline with age. Short-term memory wanes to a degree, but in contrast to a person with dementia who tends to forget a whole experience the normal older person will only forget parts of the experience. For example, where the person with dementia might forget altogether having been to the cinema, the normal older person might just forget some details of the film. New learning becomes more difficult for the normal older person, the ability to solve novel problems declines and the speed of mental processing slows. There is a speed — accuracy trade-off, however, with the normal older person tending to make fewer errors.

There is also an age-related tendency to have some increased difficulty in word-finding and remembering names — a situation that most of us have experienced as having a word 'on the tip of the tongue'. In most cases the missing word appears a bit later without prompting. Associated anxiety about not getting the word out may often magnify the problem. In addition, those people who are more 'tongue-tied' than others and have always had some difficulties in expressing themselves find that the ageing process exacerbates this tendency.

The accumulation as one ages of all the knowledge and products of previous cognitive processes is known as 'crystallised intelligence'. Crystallised intelligence does not decline in normal ageing; rather, it often increases with maturity and brings greater wisdom. It is one of the reasons that societal elders are held in high regard and hold senior positions in most cultures. There is no precise point at which normal age-related cognitive changes can be said to become a pathological entity (disease), and there is considerable debate on the issue in the scientific community. There are, however, some warning signs. Normal age-related decline takes place over decades, so decline over a shorter time, months or a few years, is liable to be pathological.

This is particularly the case if the person's functional performance has declined relative to their peers and they are unable to adapt to maintain functioning in normal life.

WHAT ARE THE MAIN TYPES OF DEMENTIA?

Alzheimer's disease is the most common type of dementia in most countries in the world, the main exceptions being Japan and China where vascular dementia predominates. Alzheimer's disease accounts for about...