Riverview Psychiatric Center

Psychology Articles by Dr. Arthur Dingley - Living With Dementia

Dr. Art Dingley

Dementia is a big problem. This is really a matter of demographics. Dementia is a disease of old age. The population is aging because we live longer. The fastest-growing age bracket is people over eighty-five. Maine now has a higher percentage of seniors than any other State. We have heard dire predictions that the “baby boom” generation will crush the health care system as it moves into old age. This has turned out to be a lot of blather because the boomers are a healthier group than their predecessors. However, if the boomers acquire dementia at the same rate as previous generations, we will have trouble.

There are several causes of dementia. Rarely, dementia may have a reversible cause, like niacin deficiency. Other causes are not reversible. Dementia may be caused by Parkinson’s Disease. It may be caused by Creutzfeldt-Jakob Disease which has been much in the news lately because one form is communicable: Bovine Spongiform Encephalopathy (BSE), often called “mad cow disease.” Pick’s Disease is a rapidly fatal dementia which strikes people in their forties and fifties. Lewey Body Disease resembles Alzheimer’s Disease, but strikes younger people and progresses quickly. Huntington’s Disease is a genetically transmitted neurological illness which includes a form of dementia. Fortunately, these conditions are rare.

Perhaps a fourth of all cases of dementia are caused by cerebral vascular disease, blockage of tiny arteries in the brain. I’m getting worried about this. Our national epidemic of obesity has set off an avalanche of diabetes. Diabetes causes severe damage to small blood vessels. Obesity contributes to high blood pressure, which contributes to multiple small strokes. As these obese diabetics move into late middle age, the number of cases of vascular dementia will rise rapidly.

Alzheimer’s Disease accounts for most cases of dementia. It is a relentlessly progressive, and invariably fatal, illness. The cause in unknown, but the process is well understood. An abnormal protein, called beta amyloid, begins to accumulate in the brain. Our cells have an internal skeleton or scaffolding. The tubules which form the skeleton of brain cells (neurons) become deranged and tangled. The brain cells are probably being “poisoned” by beta amyloid. As the cells die off, tiny holes appear in the brain tissue. These changes are always found in the brains of people with Alzheimer’s Disease. However, there is no “test” for Alzheimer’s Disease. The damage can’t be seen with computed axial tomography (CAT scan) or magnetic resonance imaging (MRI scan). It isn’t feasible to take a biopsy of brain tissue from everyone with symptoms of dementia. For now, Alzheimer’s is diagnosed clinically, after eliminating the other possible causes of dementia.

How are people affected by Alzheimer’s Disease? Dementia is progressive cognitive decline. Cognition is the complex process of thinking. Our brains receive information from the environment, assign meaning to it, compare it to information already learned, and prompt us to act or respond. Dementia disrupts every aspect of thinking, but memory is usually the first to be affected. Long-term memory is often preserved while short-term memory erodes. The person can remember details from childhood, but not things that happened last week. She may begin to confabulate (make up things she cannot remember) or gloss over the problem by dismissing the information as unimportant. As memory fails, the person becomes disoriented. First she loses orientation to time (day, month, season, year), then to place. People with advanced Alzheimer’s will wander aimlessly unable to recognize once-familiar surroundings. Dementia does not come and go, or get better and worse. It just gets worse.

Although memory loss is usually the first symptom, other aspects of information processing are soon affected. Visual input may be deranged and the person may begin to hallucinate. The hallucinations often take the form of people or animals. Alzheimer’s Disease may cause aphasia – the person may know what she wants to say but be unable to get the words out. It may cause agnosia - the inability to recognize or name a familiar object or face. A person with agnosia may refer to a pen as a “writer”, or a faucet as “the thing where you fill the teakettle”. Alzheimer’s Disease often causes apraxia – the inability to perform a learned task. A person with apraxia may not be able to use a comb or toothbrush, even though his+ muscles are working just fine.

As the disease progresses, the person with dementia needs increased supervision and assistance to prevent mishap. Family members quickly become overwhelmed by the demands of caring for a demented relative. Providing home care for a demented relative is especially difficult when she has personality changes and becomes agitated, fearful, or aggressive. Sleep may be disrupted by dementia and caregivers must be alert around the clock to ensure that the demented person is not wandering away or attempting to use the stove in the middle of the night. At this point, nursing home care is required to meet basic needs for nutrition, cleanliness, and safety.

How common is Alzheimer’s dementia? The risk increases with age. At the age of sixty, about one percent of the population has Alzheimer’s. The prevalence doubles every five years – two percent at sixty-five, four percent at seventy, eight percent at seventy-five, sixteen percent at eighty, thirty-two percent at eighty-five. Roughly two thirds of people ninety years old have Alzheimer’s disease. Although we don’t believe that the risk of dementia is greater than in the past, there are certainly more cases of dementia because people are living longer.

Can Alzheimer’s Disease be prevented? It was often observed that education appeared to protect against dementia – the more years of education one accrued, the less likely one was to have dementia. Research has shown, however, that education somehow delays the onset of dementia, but does not prevent it. It is clear that many people have “double dementia” – both Alzheimer’s and vascular dementia. Since vascular dementia is caused by “lifestyle” factors, people who have used alcohol in moderation, have maintained physical fitness, and not smoked may be less affected by dementia even if they acquire Alzheimer’s Disease.

How is dementia treated? Alzheimer’s Disease results in a deficiency of a neurotransmitter (chemical signal) called acetylcholine. There are several medicines which increase brain levels of acetylcholine. These medicines may slow the progression of dementia, allowing people to remain independent, or at home with supervision, for longer periods before residential care is necessary. Other medicines may treat the anxiety, agitation, and hallucinations of Alzheimer’s Disease. As people with dementia move through the stages of cognitive decline, they may begin repeatedly to express an idea or emotion which appears nonsensical. Sometimes this idea or emotion is a link to the past, particularly to “unfinished business” which is now seeking resolution. Brief, supportive psychotherapy, particularly a technique called “validation therapy” may help. Research is underway to create antibodies to the beta amyloid protein which accumulates in the brains of people with Alzheimer’s Disease. If this succeeds, there may be a “vaccine” within the next five to ten years.

Close family members of a person with dementia must take care of themselves, as well, to avoid becoming overwhelmed emotionally and physically. When a family member is diagnosed with dementia, caregivers should contact the Alzheimer’s Association (800-660-2871) as soon as possible. The Association is a very valuable resource. The Statewide Helpline is available 24 hours daily.

Dr. Dingley is a psychiatrist with Evergreen Behavioral Services in Farmington. He may be contacted at adingley@fchn.org

Agency information

Riverview Psychiatric Center

Psychology Articles by Dr. Arthur Dingley - Living With Dementia

Featured links

RPC news