Though rare, dementia can occur in young people –Physician


Godfrey George

A Lagos-based physician, Dr. Nwaizu Tochukwu, discusses the causes and management of dementia in this interview with GODFREY GEORGE

What is dementia?

Dementia is a medical term that is characterised by impaired ability to remember, think or make decisions in a way that interferes with doing everyday activities. Dementia in itself is not a disease. It is usually associated with neurodegenerative diseases. Dementia is primarily a term used to describe a group of symptoms that affect intellectual and social abilities severely enough to interfere with daily function.

What are the types of the condition?

The types interface or overlap with the causes and can be used interchangeably in the medical literature. There are several types of dementia, which include Alzheimer’s, Vascular, Lewis body, Mixed and Frontotemporal dementia. Alzheimer’s disease is the commonest neurodegenerative disease responsible for dementia. More than half of dementia cases result from AD. This is common in the elderly. AD is also characterised grossly by the destruction of brain cells. A salient cause of AD is the development of Beta-Amyloid protein. Under normal circumstances, this abnormal protein is swept off by the body’s immune system. When it gets to a certain level that the immune system cannot contain, it aggregates and forms a plaque called Amyloid plaque. This plaque accumulates in areas of the brain. For example, it can accumulate in the hippocampus, which is responsible for memory, thus leading to memory loss. It accumulates in other areas of the brain responsible for thinking and decision-making.

Are there stages in this?

There are five stages associated with Alzheimer’s disease. They are preclinical Alzheimer’s disease, mild cognitive impairment due to Alzheimer’s disease, mild dementia due to Alzheimer’s disease, moderate dementia due to Alzheimer’s disease and severe dementia due to Alzheimer’s disease.

The five Alzheimer’s stages can help you understand what might happen, but it’s important to know that these stages are only rough generalisations. Dementia is a continuous process. Each person has a different experience with Alzheimer’s and its symptoms. There is preclinical Alzheimer’s disease. Alzheimer’s disease begins long before any symptoms become apparent. This stage is called preclinical Alzheimer’s disease, and it’s usually identified only in research settings. You won’t notice symptoms during this stage, nor will those around you. This stage of Alzheimer’s can last for years, possibly even decades. Although you won’t notice any changes, new imaging technologies can now identify deposits of a protein called Amyloid beta, which is a hallmark of Alzheimer’s disease. The ability to identify these early deposits may be especially important for clinical trials and in the future as new treatments are developed for Alzheimer’s disease.

There is also what is called mild cognitive impairment due to Alzheimer’s disease. People with mild cognitive impairment have mild changes in their memory and thinking ability. These changes aren’t significant enough to affect work or relationships yet. People with MCI may have memory lapses when it comes to information that is usually easily remembered, such as conversations, recent events, or appointments.

Other types apart from the ones earlier mentioned are frontotemporal dementia, Huntington’s dementia, Creudtfelt-Jakob disease, korsakoff dementia, HIV-related dementia, etc.

What are the impacts of the disease on making critical judgments about reality?

People with mild cognitive impairment may also have trouble judging the amount of time needed for a task, or they may have difficulty correctly judging the number or sequence of steps needed to complete a task. The ability to make sound decisions can become harder for people with MCI. We also have mild dementia due to AD. Here, Alzheimer’s disease is often diagnosed in the mild dementia stage, when it becomes clear to family and doctors that a person is having significant trouble with memory and thinking that impacts daily functioning. In the same vein, we have what is called moderate dementia due to AD.

During the moderate dementia stage of Alzheimer’s disease, people grow more confused and forgetful and begin to need more help with daily activities and self-care. Thirdly, in this vein, there is also severe dementia caused by AD. In the late stage of the disease, called severe dementia due to Alzheimer’s disease, the mental function continues to decline, and the disease has a growing impact on movement and physical capabilities.

Others include Vascular dementia and Lewy Body dementia. Lewy bodies are abnormal clusters of protein that have been found in the brains of people with Lewy Body dementia, Alzheimer’s disease and Parkinson’s disease. This is one of the more common types of progressive dementia.

Apart from the loss of memory, how possible is it for one to lose one’s language which one had known all one’s life?

There is another condition by which one can lose their language skills known as Aphasia. There are other patterns of Aphasia but that is another broad topic on its own. Dementia may not affect one’s language.

What are the common signs and symptoms of dementia?

Common signs and symptoms include acting out one’s dreams in sleep, seeing things that aren’t there (visual hallucinations), and problems with focus and attention. Other signs include uncoordinated or slow movement, tremors, and rigidity (parkinsonism).

The commonest signs of Vascular dementia include difficulties with problem-solving, slowed thinking, and loss of focus and organisation. These tend to be more noticeable than memory loss. For mixed dementia, autopsy studies of the brains of people 80 and older who had dementia indicate that many had a combination of several causes, such as Alzheimer’s disease, Vascular dementia and Lewy Body dementia. Studies are ongoing to determine how having mixed dementia affects symptoms and treatments. These are the areas generally associated with personality, behaviour and language. Common symptoms affect behaviour, personality, thinking, judgment, language and movement.

Among these, which is the most deadly?

Alzheimer’s dementia is one of the leading causes of death worldwide. In fact, as of 2019, it was ranked the seventh leading cause of death by WHO. Elderly patients usually die from lung infections due to their inability to swallow which is a late complication in Alzheimer’s disease.

Are their risk factors?

Yes, there are. They are also associated with B-Amyloid build as I mentioned in Alzheimer’s dementia. Age, alcohol intake, smoking, family history, traumatic brain injury, hypertension, diabetes, high blood cholesterol, lack of sleep and lack of exercise could be risk factors for dementia.

How possible is it for young people to also have dementia?

It’s possible, however, quite uncommon. Many people link dementia with old age and that’s a fallacy. Dementia can occur in a 30-year-old, although rare.

We also have what we call early onset dementia which occurs in patients less than 60 years old. It’s also commoner in other dementias like frontotemporal, korsakoff syndrome, and HIV-associated dementia. Early-onset dementia is also associated with Down’s syndrome. In addition, blacks have also been found to be at a high risk of early-onset dementia.

It’s a common saying in health that dementia itself doesn’t kill the patient rather major health events while suffering from dementia, are the cause. How true is this?

Yes, it’s quite true. One should watch out for memory loss, difficulty in carrying out familiar tasks, mood and personality changes, increasing confusion, loss of concentration and focus, being socially withdrawn, depression, etc.

Struggling to follow a conversation or find the right word is one cause. When should this be a cause of worry?

Yes, humans can have this from time to time but when it becomes consistent alongside memory loss and some of the symptoms mentioned earlier, it becomes a cause to worry about.

Since age is a factor, how much would it affect people who are in management positions but are above 70?

Individuals in that position have a proclivity for smoking, alcohol, mental stress, weight gain, and high blood cholesterol. So they are at a risk for dementia, particularly, vascular dementia, which is linked to stroke and hypertension and they are also at risk of Alzheimer’s disease if they have a family history or genetic predisposition.

What should you not say to someone who has dementia?

Oh! This question is quite dicey as words not to say can be quite relative from person to person but there are general things not to bring up. Don’t argue with these patients especially when it has to do with bringing up recent events they have forgotten. Don’t bring up inflammatory words or cuss them. It happens that caring for this type of patient can be demanding and frustrating. So try not to pour out your anger on them. Don’t try to use words like, “Do you remember?” to invoke their memories as it can trigger anxiety in them or make them think they are a failure for not remembering. Try to work with them in the present.

Is it wrong to classify it as a mental illness or one condition which is more psychological than physical?

It was once considered a mental illness under the Diagnostic and Statistical Manual for Mental illness (DSM 5 category) because patients with dementia exhibit symptoms related to psychosis or mental illnesses. However, dementia is not a mental illness as dementia is organic/physical rather than mental. As I explained earlier it has to do with an insult to the brain which thereby affects the physiological pathways of the brain. I hope people will be able to differentiate between dementia and mentally related illnesses.

At what point do you think dementia patients need 24-hour care?

Patients will be needing 24-hour or hospice care once they develop complications like inability to swallow, weight loss, lung infections, loss of bowel and bladder control and inability to walk.

Why do dementia patients get so angry?

Several things might provoke anger or aggressive behaviours in these patients. Remember that dementia is a result of brain changes around the centres responsible for memory, language, and decision-making, which inadvertently makes them impaired so that the areas responsible for flight or fright response/emotions are heightened. This is important to note because these flights of emotions or outbursts are not necessarily their own doing. However, the anger can stem from pain or discomfort. These patients are poor at localising pain or telling you when they feel pain. So they sometimes express this with anger. A noisy environment can also trigger anger. They also tend to be quite anxious in a noisy environment and act out with aggression. Finally, if they cannot use words to communicate, they will rely on their behaviour to communicate.

Are there any nutritional expectations to care for people with dementia?

Yes, of course. Nutrition is tailored towards improving patients’ weight, slowing down the disease progression. Malnutrition in dementia is of great concern because these patients tend to have poor appetite which makes it important to improvise a special diet for them. These diets should be rich in proteins, vitamins and minerals. They also encouraged liberal fluid intake.

How long can a 70-year-old dementia patient live?

It varies. Some patients can last for five-10 years whereas others might be cut short due to comorbidities like heart diseases, cancer, stroke, or complications from dementia-like pneumonia.

What are the remedies?

It is salient to point out that there is no cure for dementia. It can only be managed which is aimed at slowing disease progression. There are medications depending on the type of dementia. Donepezil, Galantamine and Rivastigmine are cholinesterase inhibitors used for managing Alzheimer’s disease. These drugs are administered in tablets or patches prescribed for patients with mild to moderate Alzheimer’s disease.

Unfortunately, medications for other types are minimal. Cholinesterase inhibitors can be used for Parkinson’s disease and Lewy Body dementia but are not as effective as in Alzheimer’s disease. There is also what we call Cognitive Stimulation Therapy which aims to exercise the brain by improving memory, learning, and problem-solving skills. It involves taking part in group activities. There is a new therapy in clinical trials, gene therapy, which involves the insertion of a gene into the dysfunctional cell aimed at treating the disease. If this innovation becomes successful, it would be a game-changer in the treatment of dementia and other genetic diseases.

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