Dementia
What is dementia?
Dementia is a general term used to describe a set of symptoms which is often progressive. These symptoms often include:
- loss of memory
- mood changes
- problems with communicating
- problems with reasoning
- difficulty completing day-to-day tasks
The symptoms can occur in isolation or in combination. In the initial stages, memory loss and trouble thinking clearly may bother the senior with dementia. Seniors with dementia can become apathetic or uninterested in their usual activities, or may have problems controlling their emotions. They may also find social situations challenging and lose interest in socialising. Some may also develop agitation with disruptive behaviour and hallucination.
The senior with dementia may not be aware of these problems as they gradually lose the ability to remember events or fully understand their environment or situations.
How does dementia progress?
Dementia is progressive. This means that the symptoms will gradually get worse. In the much later stages of dementia, people will be able to do far less for themselves and may lose much of their ability to communicate. The speed at which this happens usually differs between seniors and depends on the type of dementia they have.
What causes dementia?
There are many different types of dementia, including:
This is the most common type of dementia. It accounts for 60 to 80 percent of all cases of dementia. It is due to changes in the chemistry and structure of the brain and causes brain cells to die. Problems with short-term memory is usually the first obvious sign.
This is caused by the brain not getting enough blood and oxygen. Without enough oxygen, brain cells die. This can happen after a stroke, bleeding in the brain or because the arteries (blood vessels) supplying oxygen to the brain are damaged.
- Dementia with Lewy bodies (DLB)
This type of dementia gets its name from tiny abnormal structures, called Lewy bodies, which build up inside the nerve cells in the brain. Lewy bodies cause brain tissue to break down and prevent the brain from functioning properly. Symptoms can include recurrent falls with parkinsonism, confusion and hallucinations, as well as difficulty reasoning and solving problems. The memory may be affected too. This form of dementia shares similar characteristics with Parkinson's disease dementia but with a different trajectory.
This type of dementia is usually caused by damage to the front part of the brain, and is more likely than other types of dementia to affect people at a younger age. The most obvious signs are changes in personality and behaviour.
Among persons at more advanced age (especially 85 and greater), there can be more than one cause of dementia, often both Alzheimer’s disease and vascular damage.
Dementia can also be caused by cumulative damage to the brain, which can occur in people with chronic alcoholism or repeated head injuries (e.g. former professional boxers or football players).
What is mild cognitive impairment?
There is a condition known as ‘Mild Cognitive Impairment’ (MCI). This is when there are problems with the person’s memory, but the symptoms are not severe enough to diagnose the person with dementia, particularly if the person is still managing well. Recent research has shown that people with MCI are more likely to develop dementia but having MCI does not always mean that the person will go on to develop dementia.
What is the difference between dementia and delirium?
Like dementia, delirium causes memory loss, and confusion. However, unlike dementia, delirium is usually reversible and the onset is acute.
(Read more about delirium
here.)
Why is it important to get a diagnosis?
Although there is no cure for dementia at present, if it's diagnosed in the early stages, there are ways to slow it down and preserve memory. A diagnosis can help seniors get the right treatment and support, and help those close to them prepare and plan for the future. With proper treatment and support, many seniors are able to lead active and fulfilled lives.
How is dementia diagnosed?
Dementia can be diagnosed by a GP or by a specialist doctor. The specialist may be a geriatrician, a neurologist, or a psychiatrist. The doctor may ask you to do a number of tests to check on your basic thought processes and your ability to do daily tasks. They may book more tests for you, such as blood tests, a brain scan or a more in-depth check of your memory, ability to concentrate and cognitive skills.
Can dementia be cured?
Most types of dementia cannot be cured, although there continues to be research in developing
drugs, vaccines and other treatments.
Dementia onset can be delayed or could even be potentially preventable through lifestyle changes including continuing education and learning new skill, preventing hearing loss, addressing high blood pressure, reducing obesity, stopping smoking, treating depression, increasing physical activity, keeping diabetes under control and socialisation.
A number of drugs have been developed that can temporarily alleviate some of the symptoms of certain types of dementia. These drugs include the following three cholinesterase inhibitors:
- Donepezil
- Rivastigmine
- Galantamine
In addition, another drug called Memantine can be used.
The medicines should periodically be evaluated to see if they are providing any benefit.
It is important to have realistic expectations about the potential benefits of these medicines. None of these medicines cure Alzheimer’s. With these medications started early, the hope is that the patient and their family will have an improved quality of life for a longer period.
Delirium
What is delirium?
It is a condition that causes people to be confused. They often have trouble paying attention, recognising their surroundings, and have problems with their memory. The change is usually sudden. Symptoms may come and go, and may fluctuate during the day. Sometimes they are worst in the evenings.
If you suspect that your loved one is delirious, it is important that the person is evaluated promptly to identify the underlying cause(s) and begin treatment as soon as possible. Do alert your doctor.
What causes delirium?
There are many conditions which can precipitate delirium in seniors. Common causes include:
- Infections (senior may not present typically with a fever only a change in mental status)
- Medications (especially those with high anticholinergic load)
- Pain
- Dehydration
- Constipation
Many factors can predispose a senior to delirium:
- Change in environment e.g. being hospitalised
- Being on multiple medications
- Have underlying dementia
- Have poor eyesight or hearing
How common is delirium?
Delirium is fairly common. It happens in up to a third of seniors admitted to hospital. The incidence is higher in intensive care unit patients or during perioperative period.
How do we treat delirium?
- Treat the underlying cause of the delirium. In addition to treating the acute episode, we support them by keeping their surroundings quiet and reminding them of where they are and why they are in hospital
- Relieve pain and minimise discomfort
- Maintain a regular sleep-wake cycle when possible
- Make hearing aids and eyeglasses available if the patient uses these at home
- Remove all barriers and restraints including urinary catheter where possible
- Encourage mobility and recommending cognitive activities
You can play a part too! It often helps patients with delirium to have their family and other familiar faces with them when they are in hospital.
Falls
Anyone can have a fall, but older people are more vulnerable and likely to fall, especially if they have a long-term health condition. Falls are a common, but often overlooked cause of injury. Most falls don't result in serious injury. However, there's always a risk that a fall could lead to broken bones, and it can cause the person to lose confidence, become withdrawn and feel as if they've lost their independence.
What causes a fall?
The natural ageing process means that older people have an increased risk of having a fall.
Older people are more likely to have a fall because they may have:
- Balance problems and muscle weakness
- Poor vision
- Impaired sensation, particularly in the feet, or foot pain
- A long-term health condition, such as heart disease, dementia or low blood pressure (hypotension), which can lead to dizziness and a brief loss of consciousness
- Vitamin D deficiency
- Been using medicines that affect attention (e.g. opioid analgesics, antianxiety drugs, and some anti-depressant drugs) or lower blood pressure (e.g. antihypertensive, diuretic, and some heart drugs) can also increase the risk of falling. Even some over-the-counter medicines can affect balance and how steady you are on your feet
- Poor safety awareness
Falls can also be caused by physical conditions that impair mobility or balance, hazards in the environment, or potentially hazardous situations. A fall is also more likely to happen when:
- the floor is wet or has been recently polished, such as in the bathroom
- the lighting in the room is dim
- rugs or carpets aren't properly secured
- the person is reaching for storage areas, such as a cupboard, or is going down stairs
- the person is rushing to get to the toilet
- there are electrical or extension cords or objects that are in the way of walking
- there are uneven sidewalks and broken curbs
- the person is unfamiliar with his/her surroundings
Most falls occur when several causes interact. For example, people with Parkinson’s disease and impaired vision (physical conditions) may trip on an extension cord (an environmental hazard) while rushing to answer the telephone (a potentially hazardous situation). The more risk factors a person has, the greater their chances of falling.
What are the symptoms of a fall?
Often before falling, people have no symptoms. When an environmental hazard or a hazardous situation results in a fall, there is little or no warning.
However, if a fall is partly or completely due to a person’s physical condition, symptoms may be noticed before falling. Symptoms may include
- Dizziness
- Light-headedness
- Irregular or rapid, pounding heartbeats (palpitations)
After a fall, injuries are common and tend to be more severe as people age. Falls can result in at least a slight injury, such as a bruise, sprained ligament, or strained muscle. More serious injuries include broken bones, torn ligaments, deep cuts, and damage to organs such as a kidney or the liver. Some falls result in loss of consciousness or a head injury.
Falls can cause even more problems if the person cannot get up right away or summon help. Such a situation may be frightening and may make the person feel helpless. Remaining on the floor, even for a few hours, can lead to problems such as dehydration, or muscle breakdown that can lead to kidney damage or failure.
What can happen after a fall?
Falls can cause broken bones, like wrist, arm, ankle, and hip fractures. These injuries can make it hard for a person to get around, do everyday activities, or live on their own.
Falls can cause head injuries. These can be very serious, especially if the person is taking certain medicines (e.g. blood thinners). An older person who falls and hits his/her head should see a doctor right away to make sure they don’t have a brain injury.
Some falls can be serious and result in death.
The effects of a fall may last a long time. Many people who fall, even if they’re not injured, become afraid of falling. This fear may cause a person to cut down on their everyday activities. When a person is less active, they become weaker and this increases their chances of falling.
Should I tell my doctor if I have fallen?
It is vitally important for people to tell their doctor if they have fallen, even if the doctor has not asked, so that the doctor can uncover treatable reasons behind the fall. People who have fallen may be reluctant to tell their doctor because they think falling is just part of getting older, especially if they have not been injured. Even people who have been seriously injured during a fall and have been treated in an emergency department may be reluctant to admit they have fallen.
Some older people may be reluctant to seek help and advice from their GP and other support services about preventing falls, because they believe their concerns won't be taken seriously. However, all healthcare professionals take falls in older people very seriously because of the significant impact they can have on a person's health.
How are falls treated?
The first priority is treatment of injuries, such as head injuries, fractures, sprained ligaments, and strained muscles.
The next priority is to prevent subsequent falls by treating disorders that may have contributed to the fall. Physical and occupational therapists can help improve people’s walking and balance as well as their self-confidence after a fall. They can provide tips on how to avoid falling. Therapists can also encourage people to remain active. Physical therapy and supervised balance training and stretching can help reduce the risk of falling.
How can you prevent falls?
These are some simple things you can do to keep yourself from falling.
- Talk to your doctor to
- evaluate your risk for falling and talk with them about specific things you can do
- review your medicines to see if any might make you dizzy or sleepy. This should include prescription medicines and over-the-counter medicines. Your doctor may recommend alternative medication or lower doses if they feel the side effects increase your chances of having a fall. In some cases, it may be possible for the medication to be stopped.
- Do strength and balance exercises
- Do exercises that make your legs stronger and improve your balance. This can take the form of simple activities such as walking and dancing, or training programmes. Tai Chi is a good example of such an exercise.
- Have proper clothes and footwear
- Avoid loose-fitting, trailing clothes that might trip you
- Wear well-fitting shoes that are in good condition and support the ankle
- Take care of your feet by trimming your toenails regularly and seeing a doctor about any foot problems
Have your eyes checked by an eye doctor at least once a year, and be sure to update your eyeglasses if needed. If you have bifocal or progressive lenses, you may want to get a pair of glasses with only your distance prescription for outdoor activities, such as walking. Sometimes these types of lenses can make things seem closer or farther away than they really are. Not all visual problems can be treated. However, some problems, such as cataracts, can be surgically removed with surgery.
- Make your home safer
- Add grab bars inside and outside your bathroom
- Use non-slip mats in the bathroom
- Mop up spills to prevent wet, slippery floors
- Get help lifting or moving items that are heavy or difficult to lift
- Remove clutter that you could trip over
- Ensure all areas of the home are well lit
Drinking alcohol can lead to loss of co-ordination and exaggerate the effects of some medicines. This can significantly increase the risk of falls, particularly in older people. Avoiding alcohol or reducing the amount you drink can reduce your fall risk. Excessive drinking can also contribute to the development of osteoporosis.
If you've fallen in the past, making changes to reduce your chances of falling can also help you overcome any fear of falling.
What should you do if you fall?
If you have a fall, it's important to keep calm.
If you're not hurt and you feel strong enough to get up, don't get up quickly. Roll onto your hands and knees and look for a stable piece of furniture, such as a chair or bed. Hold on to the furniture with both hands to support yourself and, when you feel ready, slowly get up. Sit down and rest for a while before carrying on with your daily activities.
If you're hurt or unable to get up, try to get someone's attention by calling out for help, banging on the wall or floor, or using your aid call button (if you have one). If possible, crawl to a telephone and dial 995 to request an ambulance. Try to reach something warm, such as a blanket or dressing gown, to put over you, particularly your legs and feet. Stay as comfortable as possible and try to change your position at least once every half an hour or so.
You should also have a good way to call for help. People who have fallen several times may keep a telephone in a place that can be reached from the floor. Another option is installing a personal emergency response system (a medical alert device) that signals someone to check in on you.
Functional Decline
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What is Functional Decline?
Aging affects all parts of our body and life. But we do not just want to live longer, we want to live better. Being able to be independent is an important part of living a high-quality life, and this is why function in our elderly is an absolute priority.
Function: the ability to take care of him/herself. This includes having the physical strength to do things as well as the mental ability to plan these actions
Image from https://www.advancedrm.com/measuring-adls-to-assess-needs-and-improve-independence/ |
Decline: this means the older person is not able to do what he/she was able to do before. This varies from person to person.
Image from http://www.fotosearch.com/photos-images/walking-down-stairs.html |
As functional decline is very broad, it can come in many forms. The common ones we see are:
- Eating less
- Becoming more sleepy and displaying a loss of interest
- Talking less to family and becoming more withdrawn
- Not moving around as much
- Urinary incontinence
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What causes Functional Decline?
Many things can cause a person to decline functionally. Conditions or circumstances that are more often seen are:
- Medical conditions such as infection, stroke, heart attack etc.
- Eating and drinking less (whether for medical or non-medical reasons) and so having less energy
- Being sad and withdrawn, having less motivation to do things
- Delirium from changes in environment, infection etc.
- Being unable to see or hear clearly
- Lack of sleep
- Change in social circumstances e.g. housing, new caregiver
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What does it mean for my loved ones?
Unfortunately, the causes and effects of functional decline are same , and the two become perpetuated in a cycle (see diagram below). This makes it all the more important to identify it early, treat it and prevent it from happening.
What can loved ones do?
Be there for your family member with functional decline. It is frightening to suddenly not be able to do things we usually take for granted. Do not blame it on age alone; bring them to see a geriatrician or physician with expertise in elderly care. Having loved ones around makes our elderly feel cherished and motivated to get better.
Geriatric Assessment done by geriatricians and a well-trained team can help identify cause for functional decline, focus on the patient's strengths and identify a remedy for him or her to enjoy a better quality of life. Treatment can involve treating acute medical conditions, function, memory, environment and / or mood.