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Dementia

WHAT IS DEMENTIA?
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Dementia is the name given to a condition marked by a loss of the cognitive functions of the brain namely the functions of the brain to do with thinking, reasoning, decision making and memory.  A lot of attention in the media focuses on loss of memory but loss of memory, particularly for recent events, is part of normal ageing and the inability to remember where one has put car keys or a name of someone met last week is normal, and it is not an indication of dementia or even early dementia.
With dementia there are severe effects on the key functions of life, for example on 
  • looking after oneself and remembering to wash,
  • finding one’s way about outside the house, for example getting lost on the way back from the shops one has visited for thirty years,
  • interaction with other people in conversation and, obviously,
  • an ability to manage one’s financial affairs or to drive.  
 
Dementia therefore is diagnosed by changes in thinking and behaviour. 
 There are two common causes of dementia which often occur together.  One of these is Alzheimer’s disease although there are probably a number of different conditions all grouped under the heading of Alzheimer’s disease.  In this disease changes can be seen in the brain now that we have easy means of visualising the brain namely MRI and CT scans.  A very small proportion of Alzheimer’s diseases comes on early and is genetically determined most of it is an unknown cause and most of it at present untreatable.  
The second cause is interruptions in the flow of blood supply to the brain. The blockage of a big artery to the brain results in a stroke which obviously can affect thinking as well as the ability to move an arm or a leg.   However what is now clear, thanks to modern imaging techniques, is that some people have multiple small strokes, but these occur in parts of the brain that do not affect movement but do affect the ability to think logically and make decisions.  These mini strokes build up in time and result in vascular dementia.  
 
Why is dementia important?
Dementia is important because it affects the individual’s ability to be independent.  It is a form of disability.  However some disabilities can be managed by helping people change  their house, for example by installing a stair lift, or providing a piece of equipment such as a little gadget for taking the tops of jam jars but when the cognitive functions of the brain are affected there is no modification or aid that can be given that compensates for the loss.
That is not to say that nothing can be done but it is a much bigger challenge than diseases that are physical and disabling.  Together with frailty it is the principal reason why people are no longer able to live independently and have to be admitted to a care home.
 
 
 
 
 
Why is it important to understand dementia?
It is now clear that dementia is not accelerated ageing, but a condition caused by underlying disease which can be complicated by loss of fitness for cognitive tasks.  This in turn is often due to mistaken beliefs for example that there is no point of ever contradicting someone with a diagnosis of dementia.
It is understanding that there is a process that can be affected as opposed to normal ageing that we need to use as the basis for how to respond to the diagnosis and what to do.  Of course ageing does have an effect on the brain, but recent research emphasised a number of important populations.  
  • Firstly the effects of ageing have been overemphasised by the type of tests that have been used to assess “intelligence” namely tests that require rapid decision making because rapid decision making is a brain function that is affected by ageing but rapid decision making is not often used in everyday life unless in a pub quiz.  On the contrary ageing, combined with experience can help people make better decisions the longer they live. 
  • Secondly it is important to identify correctible causes of dementia.  Over medication, sometimes complicated by a person who is confused making mistakes with the numerous prescribed drugs that they have to manage on a daily basis, is a cause of dementia and people with dementia usually need to review the medication they are taking and ask the doctor is it really essential to continue taking the prescribed medication, a process known as de- prescribing.
  • Thirdly it is important that everyone knows the person affected by dementia shares this understanding.  Confusion is increased if one person has a policy of agreeing with everything the person with dementia says no matter how obviously wrong whereas another person believes that they should argue with the person with dementia, even though it upsets them ,so that they are helped to make correct decisions.  The best course is somewhere in the middle, but the best course is also the course that everyone follows.
 
Can progression be slowed, reduced or reversed?
Because Alzheimer’s disease is currently untreatable although a huge amount of effort is put into finding treatment it is all to easy to assume that dementia is untreatable but there are two aspects of dementia other than alzehimer’s that require prevention.
 
What can be done?
There is a great deal that can be done with people with dementia. 
  • Firstly underlying medical problems which are causing or activating the dementia can be tackled.  The problem of overmedication has already been highlighted but it is very important to ensure that blood supply to the brain continues to flow as well as possible. If the person has atrial fibrillation or has had a mini stroke or transient ischemic attack, then it is worth taking treatment to prevent further mini strokes.
  • Secondly, we know there are a number of factors that contribute to dementia by the direct effect on brain tissue and these include
    • poor or disturbed sleep
    • stress
    • inactivity
These all have a direct affect on the brain tissue but can be modified.  Increasingly people are using music to help people with dementia as a means of managing stress and promoting good sleep for example by playing the same restful music every evening at the same time.
  • Thirdly it is very important to minimise social isolation.  This includes
    • improving hearing if that is a problem
    • Improving vision and not assuming that an old pair of spectacles will be sufficient because the old person has dementia and
    • engaging with others
Many homes now are establishing links with other groups for example with play groups because of their very beneficial effect.  In addition to humans, cats and dogs also provide companionship and affection.  In Japan robots have been used partly because of staff shortage in homes and in her book Extra Time Camilla Cavendish describes well the point that robots can play but as she says quite rightly “robots care for you – humans care about you.”
Is difficulties are increasing referral to the specialist dementia service run by the local mental health service or hospital will bring expertise and experience beyond that of the average health centre or care home. In addition the Alzheimer’s Society has a very useful advice service
 
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