It can be very distressing when a loved one starts becoming confused. It happens more commonly with increasing age, and is especially disturbing when that person was previously a vital and capable member of the family. Is this just a temporary state, or does it herald a permanent, irreversible decline? Can it be cured, or will one be relegated to feelings of frustration and helplessness? One needs to have a diagnosis in order to answer some of these questions.
WHAT IS DEMENTIA?
Dementia is a progressive or permanent decline in intellectual function. There is always structural damage to the brain, from a variety of causes. This decline in function interferes substantially with the individual’s normal social activity.
Dementia must be differentiated from delirium, which is an acute state of confusion lasting days or weeks. There can be extreme disturbances of arousal, attention, orientation, perception and affect, which can be accompanied by fear and agitation, hallucinations and delusions. Delirium is commonly caused by alcohol or barbiturate withdrawal in chronic abusers. It can also be caused by high fevers and infections such as encephalitis and meningitis. Less dramatic confusing states often occur in the elderly when there is an underlying infection, such as a bladder infection.
TYPES OF DEMENTIA
The different types can be grouped according to the causative factors:
- Degenerative causes: Alzheimer’s disease, Huntington’s chorea, Parkinson’s disease, idiopathic senile dementia.
- Infective causes: chronic meningitis, chronic tuberculosis, chronic fungal infection, chronic syphilis, encephalomyelitis, viral encephalopathy, e.g. AIDS.
- Nutritional causes: chronic alcoholism; diabetes mellitus; low glucose, sodium and electrolytes; hypothyroidism; vitamin B deficiencies, including Wernicke-Korsakoff syndrome in alcoholics.
- Brain injuries: multi-infarct dementia (repeated strokes). This is the second most common cause of dementia, and often associated with hypertension. Dementia may progress in a step-like manner with each successive stroke. Other causes are trauma from repeated brain injury, as in boxers; and epilepsy.
- Toxicity: chronic drug addiction, chronic carbon monoxide exposure, renal or hepatic encephalopathy.
SIGNS AND SYMPTOMS OF DEMENTIA
Forgetfulness is often the first sign apparent to family members. There may also be depression, decreased emotion, fears and paranoia or anxiety. Dementia usually begins slowly and worsens insidiously with time. Memory, the ability to keep track of time and to recognise people, places and objects all diminish.
Depression in the elderly can mimic dementia. Elderly people may eat or sleep little and complain about memory loss. This can be labelled pseudo-dementia, but it is the depression that needs treatment. True dementia sufferers usually deny any loss of memory.
Speech patterns may change and sufferers often have problems finding the right word, and difficulty with abstract thinking. Insight and judgment become impaired. Personality may change or a particular trait becomes exaggerated, for example, an obsessive person may become unbearably pedantic and rigid. Interests may become restricted, and the sufferer’s outlook more rigid. The memory and other impairments may vary greatly from time to time.
Performance at work may slide. Often people with dementia are initially able to hide their deficiencies well; they avoid complex activities such as balancing a cheque book or paying bills. They may become frustrated at not being able to perform daily tasks, and forget to turn off the lights or the stove.
Patients with subtle signs of early dementia may at times become acutely and severely disturbed and confused. This is usually due to sudden stresses or change of familiar routine. An example would be a fall in which he/she breaks a hip leading to hospitalisation, anaesthesia, surgery, pain and sleep medications, frequent staff changes and a move to a nursing home. The net result is the sudden transformation of a once docile patient into a delirious manic needing sedation.
Dementia progresses at different rates in different people and in different conditions. Usually, progression of the disease is more painful to the family than to the patient.
In its most advanced forms, dementia leads to a near-complete destruction of the brain’s ability to function. Sufferers become more withdrawn and less capable of controlling their behaviour. They have noisy outbursts and mood swings, and tend to wander. Eventually they are unable to follow conversations and may lose the ability to speak.
ALZHEIMER’S DISEASE (AD)
AD is the commonest cause of dementia in the senile and pre-senile population; 10% of those older than 65 years and 50% of those older than 85 years will get it. Memory loss is the most prominent early symptom. AD is due to degeneration of cells in the cerebral cortex. The brain eventually displays marked atrophy (shrinkage), seen at postmortem examinations. The dementia usually progresses steadily, becoming well advanced in 2 – 3 years.
WHO WILL GET AD?
Genetics plays a significant role in determining susceptibility to AD, but environmental factors must also be considered. Traumatic injury to the head, chronic exposure to aluminium or silicon, exposure to environmental neurotoxins and free radical damage (oxidation) have all been implicated as causative factors.
Folic acid and/or vitamin B deficiency, leading to raised homocysteine levels, contribute significantly to rapid progression of AD.
Genetic testing has recently become more widely available, and a strong association has been found between cardiovascular disease (CVD) risk factors and the development of AD. Identification of high cholesterol levels, hypertension, diabetes and smoking in mid- life is associated with a 20 – 40% increased risk of dementia in later life. This rises to 75% if the person is obese.
If the person tested is found to carry a certain gene called Apo E4, his/her risk of developing AD is further increased. Fortunately, this risk responds very well to healthy diet, cessation of smoking and cutting out alcohol consumption. People who do not carry this gene, would not reduce their risk by making lifestyle changes only.
For information on genetic testing in South Africa, please refer to the website www.gknow- mix.co.za
The cost of a CVD risk profile test is about R2 500 and provides lifelong valuable information.
Abnormal fingerprint patterns have also been found to be associated with AD and Down’s syndrome. If these patterns are detected early in life, a focused preventive approach can be instituted.
Aluminium is found in:
- Drinking water
- Foods (baking powder, beer, cola drinks, non-dairy creamers, processed cheese, table salt, tea and wine)
- Medical products (antacids, anti-diarrhoeals and dental fillings)
- Toiletries (deodorants, toothpaste and household detergents)
- Cooking (aluminium pots and aluminium foil)
In all forms of dementia, all possible causative factors must be sought and treated. This requires taking a careful history, and performing thorough physical, psychological and neurological examinations. Neurological testing and blood, urine and hair analyses are important, as are scans of the brain.
A diagnosis of AD is made only when all other conditions have been excluded.
It is important to encourage avoidance of all know sources of aluminium, especially in the early stages. A diet rich in magnesium, especially vegetables, whole-grains, nuts and seeds, helps to block the absorption of aluminium into the blood and brain.
Since oxidative damage plays a large role in the development and progression of AD, it is important to supplement with antioxidants as early as possible. Darkly coloured fruits and vegetables that are high in antioxidants are vital, and diet can be supplemented with vitamins C and E.
Thiamine and vitamin B12 deficiencies impair brain function, and these should be supplemented if levels are low. The earlier these are detected, the less permanent the resulting nerve damage will be.
Zinc deficiency is one of the most common nutrient deficiencies in the elderly, and seems to be a major factor in the development of AD. Supplementation has been shown to improve memory, understanding, communication and social contact in AD sufferers.
Phosphatidylserine is the major phospholipid in brain tissue, and supplementation has been shown to improve mental function, mood and behaviour. L-Acetylcarnitine supplementation is not only also useful in slowing the progression of AD, but will benefit people with even mild mental deterioration.
The herbal extract of Gingko biloba offers much benefit in early-stage AD, and also in mental deficit due to vascular insufficiency and depression. It may or may not help in more advanced AD. It must be taken for at least 12 weeks to determine effectiveness.
Huperzine A is an extract of club moss and has been used extensively in China for the treatment of dementia, without any significant side effects.
In the advanced stages of dementia, it is helpful to maintain a familiar environment and routine for the patient. A large daily calendar and clock can help to orient the patient. Avoid scolding, as this may only make matters worse.
One need not feel helpless when faced with senile dementia or AD. It is important to encourage a healthy lifestyle and to eat a healthy diet always, as this offers the best chance of avoiding dementia in later life. If one has known CVD risks, it is worth taking advantage of the new genetic testing in order to predict the possibility of developing AD. At the first signs of memory loss, start active supplementation as outlined above.