CLINICAL APPROACH TO DEMENTIA
Dr. Mathew Abraham, MD, DM
Sr. Consultant Neurologist, Indira Gandhi & Lakshmi Hospital
The improvements of economic and health indices since independence have led to an increase of life expectancy from about 32 years at the time of Independence to about 70 years now. An increasing proportion that about 10% of the National population will be above 60. In Kerala it will be even higher – 13%.
The older one grows, the higher are the chances of a significant loss of mental faculties. For every 5 years survival after 60, there is a 5% rise in the risk of dementia – at 80 years of age one has a 20% chance of being demented.
The loss of cognitive function may involve memory, language, behaviour, visuo-spetial orientation, gait, bladder and bowel control, and executive functions. Even the deterioration of functions to a lower level than before would constitute a dementing process. The initial symptoms depend on the initial area of involvement, but over a period of time, all the above faculties will get involved, till the patient becomes helpless and bed bound, succumbing to injury or infection.
When a patient is assessed for dementia, three questions have to be addressed. I) Is it dementia or something that looks like dementia ? II) Is it a treatable dementia ? III) If not treatable, what can be done to ameliorate the symptoms and improve quality of life ?
The loss of a single cognitive faculty does not constitute dementia. Also a patient with anxiety and depression can have an apparent deterioration in his mental faculties, but this would be pseudo dementia. Treatment with anti anxiety and anti depressant drugs would restore him to normal.
If the doctor has made a diagnosis of true dementia, and effort should be made to pinpoint treatable causes-brain tumours, subdural haematomas, NPH, substance abuse, vitamin B12 deficiency and hypothyroidism would be some of the treatable causes. It is vital to identify and treat these conditions early, if this is not done, many of these conditions produce irreversible damage.
We are finally left with a group of patients in whom the dementia may not be fully reversible. Alzheimer’s disease (and its variants) and multi infarct dementia would constitute the bulk of this group. Proper treatment of diabetes, hypertension and hyperlipidemia may make a difference, especially in the multi infarct group, besides abstinence from smoking.
For the unfortunate patients with a confirmed diagnosis of AD, not much can be done. It is important to educate the care givers and to help sustain their morale. The individual symptoms in a patient that can cause the maximum stress to the care givers should be identified and specifically targeted. Aggression, violence, agitated behaviour, restlessness, wandering tendencies, hallucinations and incontinence are some symptoms that can be effectively ameliorated. The anti cholinesterase inhibitor drugs like Rivastigmine, Donepezil and newer drugs like mimantine show some scope to retard the relentless progression of the disease. Periodic review of the person should be done to identify any treatable cause.
The doctor must deal with these patients and their relatives with great sensitivity, empathy and compassion at all times.