Dementia – a forgotten epidemic
Feb. 3, 2017
The majority (60%) of people with dementia are female mostly because women live longer on average. The World Alzheimer Report 2011 revealed that in countries like New Zealand, only 60% of cases are diagnosed or documented, pushing up actual numbers to alarming levels. The cost to carers, families and society is enormous and will impact on us all.
As GPs, we have three frequent scenarios present regarding memory loss. The first is the patient worried about themselves – this is normally less of a concern –perhaps a person who is aware their memory is not as sharp as it once was and are overly concerned that it is dementia. Most often, it is not, but the fear of dementia is terrifying. The second presentation is where we, the staff at Medplus, begin to notice new deficits in a patient, who may gradually begin to fail to attend appointments or come at the wrong time, or forgets conversations we have had previously. The third presentation is by the worried and distressed partner, sibling or adult child of a patient who have come in with concerns about their loved one's memory or behaviour. Quite often, this is just the beginning of a long and difficult journey for that family.
The symptoms of dementia
- Inability to remember recent things – not just forgetting a few names and numbers (which is normal) but doing so at a much greater frequency than would be expected or repeatedly asking the same question.
- Forgetting how to do tasks or use equipment – for example, being completely overwhelmed at the thought of cooking a regular family meal or forgetting how to use a credit card or the TV.
- Disorientation in place - for example having to ask the way to get to a familiar destination or getting lost in their own neighbourhood.
- Disorientation of time – losing track of the time or date and acting inappropriately as a consequence, for example eating breakfast at dinner time or attending appointments on the wrong day.
- Losing things – how did the car keys end up in the freezer or the newspaper in the oven?
- Trouble finding the right word – starting to use words like "thingy" or calling a watch a clock.
- Poor judgement – making decisions that they would not normally, for example giving away more money than can be afforded. This leads to great vulnerability regarding door to door or telephone salespeople.
- Mood swings – people with dementia can easily become cross or sad.
- Personality changes – this can be very variable. Some people with dementia can become passive and remain cheerful but others unfortunately become disinhibited and may use coarse language or be uncharacteristically rude.
- Lack of initiative – for example, needing prompting to do routine tasks like manage personal hygiene.
Many people with early dementia do not like to admit they have a problem and will get cross and defensive when attention is drawn to their difficulties. The world can become a very frightening place for them and they worry about their future and the impact on their loved ones. Often, those with good social skills will pick up that they have forgotten something and will "confabulate" or fabricate imaginary experiences as compensation for loss of memory, often in a very convincing manner. Thus, in early dementia one has to have a high index of suspicion and ask probing questions to find out if there truly is a problem. In later dementia, the patient lacks any insight as to what is happening and will often deny any problem and as a consequence will also refuse help.
Types of dementia
Alzheimer's is the most common and well known type of dementia, but other brain disorders can and do frequently cause dementia. These types of dementia often present themselves with very similar symptoms. It is often difficult to determine which type of dementia a patient has, and some people experience multiple types of dementia concurrently, which is called "mixed dementia."
Alzheimer's disease is by far the most well-known and common type of dementia causing two thirds of cases. The mechanisms behind Alzheimer's disease aren't well understood but the most distinguishing feature of Alzheimer's disease is the build-up of amyloid plaques and tau tangles in the brain.
There are many therapies, both pharmaceutical and non-chemical which can temporarily increase functioning and improve the spirits of the person with Alzheimer's disease, but no treatment has proven to be effective and the disease is progressive.
Vascular dementia is also known as "multi-infarct dementia" and is the second most common cause of dementia. It is caused by multiple tiny clots or bleeds within the brain (strokes) and often there is a step wise increase in symptoms following subsequent strokes. Unlike Alzheimer's there are often active treatments that can prevent further strokes, for example aggressively managing cholesterol levels, blood pressure, having treatment to prevent blood clots, controlling abnormal heart rhythms and surgically clearing out blocked arteries in the neck.
Lewy Body Dementia
Lewy body dementia is much less common but is the third cause of dementia.
Lewy bodies abnormal proteins that somehow appear in nerve cells and impair functioning.
Frontotemporal dementia is rare, and is the fourth most common type of dementia. Unlike the types of dementia discussed previously, frontotemporal dementia is marked more by behavioural and emotional changes than by cognitive impairment. In fact, memory is preserved in people with frontotemporal dementia. Frontotemporal dementia occurs when the frontal or temporal lobes of the brain are damaged or shrink.
Other Causes of Dementia
Just about any condition that causes damage to the brain or nerve cells can cause dementia. For example, people with Parkinson's disease will often exhibit dementia in the later stages of their illness. Huntington's disease, Creutzfeldt-Jacob disease and alcoholism can all lead to memory and cognitive impairment.
Not only do we need to care for those with dementia, but we also have to care for and support their carers and families. If you are concerned about your memory, or a loved one's memory do make an appointment and come in and see a Medplus GP. It is often tricky to persuade someone with memory loss to seek help themselves, so it really helps if we are briefed fully by family so we can gently ask probing questions when we next see the patient. It helps if a family can be honest with their loved one and tell them about their concerns, but we realise that this can be exceedingly difficult and can sometimes put serious strain on relationships. We obviously always have to respect a patient's privacy, but we can also try and ensure we keep tip offs about memory loss secret.
Once suspicious about memory loss the GP will want to get a very detailed history of what has been happening, will perform a brief physical exam and will probably arrange some laboratory tests. Often, we will get the patient to undertake some standardised memory tests at the surgery – these take about 30 minutes with the nurse. We have great access to specialist services at North Shore Hospital and can refer on for a specialist opinion if we believe there is a problem that needs further investigation. We will continue to be closely involved with management of the symptoms of dementia.