Monday, December 23, 2013

Dementia and Preparedness

Remember that not everyone with dementia is disheveled or unkempt.  Some of them are well groomed, and this can make recognizing that they have dementia, more challenging than it might normally be.


  This week, I was finishing up some Christmas shopping all the way in Richmond, and I bought some additional colonial style kitchen chairs.  Now, family and their girlfriends and boyfriend could all sit around the kitchen table as well as the dining room one.   They were a terrific buy, but my diesel car couldn't bring a single one of them home.  I paid, and then on Saturday, my husband and I went to pick them up.  After we loaded them into his truck, we were both hungry and decided to stop at the closest fast food restaurant before heading for the long trip home via the highway.
                   I selected a salad with grilled chicken, and my husband got the largest burger with fries.  I crunched the salad while my husband, who can eat absolutely anything and remain slim, finished most of  his food in record time.  He returned to the line to get a sundae while I sat munching the salad and extracting the cherry tomatoes which should have been used the day before.
                   All at once, a woman in her sixties sat down in the booth across from me, where my husband had been, right in front of his drink and remaining food.   "Excuse me", I said, swallowing poorly chewed lettuce,  "My husband was sitting there, and he'll be right back".    "Oh", she said, looking embarrassed and anxious, and she quickly moved to the next booth, trying to avoid my gaze. I tried to be calm and polite because I thought she might have a dementia issue.    About two minutes later, her husband, who looked to be in his eighties joined her with the food.  He couldn't eat there for some reason, but she could, and so he watched as she hungrily ate the burger, french fries and a drink.  I concluded from the conversation between them that her husband, the older of the two, was quite clear and was the driving force in their relationship, but that the woman, who was sweet and very pleasant, was somewhere in the continuum of one of the dementias.   How sad.  She sat with me because I looked fairly friendly, but she did not know that she didn't know me, or that it was inappropriate to do so.  However, when I mentioned that my husband was coming back momentarily, she knew enough to be embarrassed and anxious at her faux pas.  They left before we did, or I would have said Merry Christmas as she departed.
                 When I was young, I don't think I ever saw people with dementia in any setting other than the hospital.  However, in the last few years as people live much longer than they used to, I encounter them fairly often.  I have called police when I noticed an elderly gentleman wandering aimlessly on the interstate in recent subzero temperatures.  I saw a woman with dementia having difficulty banking recently.  A close friend brought her father-in-law with dementia to live with them, until his passing.
                There are many different types of dementia which afflict human beings.  It is not just a specific illness, but there are multiple potential causes of adult onset dementia in someone who was perfectly sane and thinking clearly prior to onset.   Let's start by mentioning some of the causes of correctable dementia.  Not all cases of dementia result in a downhill slide to insanity with drooling !   Some of these causes are reversible.   Depending upon its location, a space occupying lesion can cause dementia.  This can be a benign growth in the brain, or a cancerous one.  I have a friend who is a writer who had an encapsulated tumor removed from her brain, and she is just about at 100% of full mental and physical function now.  
             Something called normal pressure hydrocephalus can occur in adults, and look an awful lot like Alzheimer's Disease, but be completely treatable when a shunt is added.   If the procedure is performed early enough, then dementia disappears. It is estimated that many cases of NPH are simply undiagnosed and that the patient may be treated for Alzheimer's, when a correctable condition actually exists.    TIAs (transient ischemic attacks) or mini-strokes can also cause memory deficits and peculiar behavior.   These can be treated medically or surgically depending upon cause.  Severe hypothyroidism can also cause something called myxedema madness, which certainly looks like dementia to me !   Not everyone with hypothyroidism is obese, because some patients naturally adjust their appetite downward in a hypothyroid state, and a few actually lose weight in response to diminished peristalsis with poor appetite.  This is also somewhat reversible with proper and gradual replacement of thyroid hormone.
              Less reversible causes of dementia include vascular dementia. This type of dementia is a result of diminished oxygen making it to the brain as a result of vascular insufficiency.  There are treatments for this, but this is less reversible than the aforementioned varieties. Sometimes a carotid endarterectomy (the cleaning out of arterial clogging of the arteries in the patient's neck.) can be beneficial to some patients.
             There are also elderly people who may have been functioning well with treatment for a mental illness.  Some people with bipolar disorder may do well with treatment and then experience a cognitive decline in old age. These patients need to be followed by both a psychiatrist and a neurologist, and the two need to speak with one another periodically.
            Lastly, the cause of dementia most of us consider is Alzheimer's Disease.  In Alzheimer's Disease, the connections between the brain cells deteriorate, and then brain cells themselves degenerate and die.  We do not yet have a cure for this, but early cases, once detected, can sometimes be slowed and cognition kept stable for longer and longer periods.   Drugs like Aricept are helpful to some, and drugs like Gefibrozil which are anticholesterol drugs can be helpful also.  In these patients, if you can diminish the fine netting of cholesterol plaques from forming in the brain, then the amyloid plaques characteristic of Alzheimer's cannot deposit there as readily.     Alzheimer's Disease can be very strange indeed because certain complex intellectual functions may remain intact, yet very simple functions might be gone.  There may also be aggression or anger issues.
            As we move through life, we all forget things. Most of us simply have a fair amount going on.  The early signs and symptoms of Alzheimer's are different though.  They may not simply be a missed appointment.  A friend once said, "Alzheimer's is not when you momentarily forget your grandchildren's names, or scramble them. It's when you momentarily forget you have grandchildren !"    I think this is a good example.

           People with Alzheimer's Disease might do the following.

   1. Forget a specific conversation, and not recall it later when prompted about the details of the conversation.
  2.  Difficulty in finding the right word from our own lexicon, or using the absolute wrong word for something.   (Be careful here, a lot of disorders including stress, make it hard to pull words.)
 3.  Mispronunciation of simple words, or a gradual decline in reading or writing skills often in a person who
    had excellent skills in this regard prior.
4. Forgetting the order of tasks which were once routine for them.   Forgetting how we pump gas, or the order in which we head into the shower, etc.   Forgetting the way home from a grocery store a mile away, etc.
5. Reasoning skills will deteriorate.  Managing a checkbook or money might become difficult for them.
  One friend of my parents lost a significant sum of money as a first sign of his Alzheimer's.
6. Becoming stressed out my normal problems that they used to handle effectively, like what to do with burning potatoes on the stove.
7. Emotional lability.....   Being more upset or more angry than is appropriate given the situation.  Remember that these patients may well realize that something is wrong, and many of them become depressed as a result.
There may also be wandering, difficulty sleeping at night, and delusions, often about missing items. Sometimes there is paranoia.

              It is therefore extremely important to get a proper diagnosis as early as possible in dementias.   Some of them are reversible and some of them are not, and the strategy then becomes the best care possible aimed at slowing deterioration as much as possible.  Some patients deteriorate quickly and others continue at a slightly diminished rate for an extended period, something passing eventually from something else entirely.   There is no test for Alzheimer's Disease specifically, and so a neurologist is probably one of the best places to go.    Sometimes other neurological disorders might impede memory and behavior.  Sometimes multiple sclerosis, or even Parkinson's Disease will manifest with subtle neurological changes.

             As America ages, the simple number of people experiencing life on some part of the dementia continuum will increase.  This is in part, why I am seeing more patients with dementia out and about as much as I am.    Please take your loved ones for proper diagnosis as soon as you can.  Treatments to slow all of these disorders do exist, and there are also some pioneering studies in Virginia.  In addition, be as kind as possible to these people, if you can.   It must be frightening to be losing part of your cognition, and have other parts of it intact. 

              Of course, we are a preparedness based forum, and having a family member with dementia is a challenge all its own, even in good times.  In an emergency or during an evacuation situation, your family member will likely deteriorate, at least during the event.  It is important that your formulate a plan for emergencies for your relative with dementia, aimed at trying to keep as much routine intact for them as possible..   For some of you, your relative with dementia may already be living with you, and you may be managing health care, and their finances.   For others, they may be slipping gradually while living independently, and might need to be picked up and aided by you in an emergency. (Picking them up in an emergency could be a challenge, because they might not wish to come with you.)   For others, you may have enough on your plate and may need to consider a memory care facility.   A family friend of ours spent her last several years in one of these, here in Virginia, and it was truly a lovely place.  I visited often, and so you should not be afraid of using such a place if and when, a need to do so arises.  In a place with a regular routine, some patients actually improve, as our friend did.       It is essential however to be considering the impact the dementia of a relative might have on your preparedness and emergency plans.


Dani said...

Jane - My mother-in-law suffered from dementia in the last 5 years of her life. It is certainly NOT an illness I would wish on anyone, nor their families. Would that they could find a way of preventing it, or, better still, curing it...

Merry Christmas, Jane - to you and your family.

Gorges Smythe said...

Old age isn't always a blessing. I watched my dearest aunt die mentally long before her body gave out. The saddest moments were those when she realized her own condition.

JaneofVirginia said...

Dani, A number of physicians I know take Gemfibrozil (Rx) because they believe that decreasing general plaques in their brain due to cholesterol will also prevent the amyloid plaque deposits which are so problematic in Alzheimer's Disease. I am not sold on this strategy enough to take a drug on a daily basis.
Generally, we do not have Alzheimer's in our family. My mother did have a vascular dementia which her physicians said was caused by 5 ppd smoking from age 19-83. I have never smoked, and I am afraid that's the best I can do in terms of prevention.
Dementia of any cause can be a terrible illness. Thanks for posting.

JaneofVirginia said...

Yes, many people with dementia don't realize that they are failing. Some remain very pleasantly confused. However, I have recollections of those who clearly knew that they did not know things they should. Thanks for posting, Gorges.

Whisper Mist said...

Hi Jane,

My mother's in the late stage of Alzheimer's. She still recognizes me, however, unable to form any kind of sentence in English other than a few repetitive words. The odd part is she can still understand and speak German to a much better extent. It's been a very long and heart breaking journey to watch this deterioration process. I've heard it described as " the long goodbye." It sure is.

I have recognized Alzheimer's in the community as well where one spouse holds onto the other as long as humanly possible. Ultimately, we reach that point where we can't care for our loved ones any longer. That might have been my most difficult moment ... letting go.

*Merry Christmas ... Helga

JaneofVirginia said...

Helga, Thank you for sharing this and taking the time, on Christmas Eve to post this. Yes, I think the moment of realization and of letting go must be the most difficult. No one can maintain a safe environment with someone who is healthy but also in the throes of dementia, indefinitely, no matter how much they love that person.
Merry Christmas.

BBC said...

I'm looking forward to losing it, I won't be disturbed by so many things.

JaneofVirginia said...

I hate to break this to you, BBC, but statistically, most people don't ever develop dementia. However, you do have the healthiest attitude toward it, if you ever do. My Dad never developed dementia. He was sharper than I am (and I hesitate to say, his physicians too) right up to the moment he started the next life !