EDmedblog. Health News and Information

Many older people like to think back over their lives and this can give great pleasure. One of the assets that a dementia sufferer usually has are his or her early memories. This ability is sometimes used therapeutically in day hospital and elsewhere, for example encouraging people with dementia to draw pictures of their past, use photographs and other visual material to make a collage, or write notes if this is still possible. A folder of relevant material or a box of objects relating to the past can be used many times in an attempt to bring out happy memories. Old photographs of family, friends, holidays, weddings, and so on are also helpful. Records, or somebody playing music from the past on the piano, will often evoke memories that may stimulate conversation.

An alternative approach is to use stimuli, such as pictures or music, as part of a simple game. Often the questions can be made up as one goes along and a single object can be used repeatedly as the basis for different questions.

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Coping with dementia can generate two different types of family problem. The first is the stress that can be caused by the demands that the disease process makes on the carers and often their children. The second, connected with the first, is the ill-feeling that can sometimes be fostered within families because one or two members feel that they are taking most, if not all, of the responsibility and providing the greater part of the care.

It is important that all members of the family are involved in making decisions about the pattern of care that is to be provided and the support that is required. If you are a lone carer among others who are helping only a little or not at all, it may help to arrange a family conference so that they are all aware of how you are feeling and what you are having to cope with. If you are beginning to feel that you have gone as far as you can on your own, make this plain in a sensitive way and ask the others not just whether they can help, but how they can help. If the time has come when lack of additional support means the sufferer will have to go into an institution, for example, they have to realize that this is a family decision and not just yours. You have done all that you can and they are saying that they have done all that they can. Even if you are the mainstay of the care that is being given to your relative with dementia, it is not just you that is responsible for any change in the pattern of care, but all your family together. In other words, the change is occurring not just because you can’t carry on but because they can’t help either. Above all, don’t carry on nurturing ill feelings beneath an apparently unworried outward appearance. Dementia is a family disease, and the whole family has a responsibility to anyone suffering from it.

When younger relatives take an aged parent with dementia into their household, this often has an impact on their own children. Children can suffer anything from the loss of their bedroom to less personal attention from their parents, though they tend to be remarkably good at coping with situations like this and adapt very well. It is often the parents’ worries on behalf of their children that are the problem, rather than the effect on the children themselves. Sometimes, however, children can be affected adversely and there is no way of predicting this in advance. Fear, particularly in younger children, can often be overcome by explaining what is going on and why their grandparent is now so different, and also letting them see how you handle situations and relate to their grandparent. Very often children form a delightful relationship with a demented elderly person, particularly in the earlier stages of dementia, and this is probably beneficial to all involved. Children’s love can be very different from that of adults — a natural expression of affection rather than a feeling of duty, which is so often a part of the emotional relationship between an adult and his or her ageing parent.

The biggest problems usually involve teenagers. They may be embarrassed to bring their friends home and feel isolated as a result; they can feel reluctant to let their friends know the situation, in case they become the object of ridicule. There may also be clashes, either because they are asked to help or because although they would like to, it would conflict with the demands made upon them by the usual teenage activities. It is very important that they understand what is going on; sometimes, as is the case with younger children, teenagers can make a major and very positive contribution to the care of a person with dementia.

It is essential, when accepting an older person with dementia into your home, not to expect that the whole family should arrange their lives around the sufferer. The other family members will still need time and attention from each other, possibly even more so than before, and everyone will have to be very sensitive about one another’s needs. Hostility or aggression in one member of the family should not be allowed to spread; rather, the underlying stresses and strains should, if possible, be addressed.

In some cases, despite the best of intentions, taking a relative with dementia into the family is disastrous. If this happens, you have to rest content with the knowledge that you have at least tried to do the best that you can. It is important not to feel guilty about exploring alternative approaches to care. It is the integrity of your own immediate family that is most important. If this breaks up, not only will the sufferer lose out, but so will everybody else. Take seriously any tendency to arguments and family unhappiness before it goes too far.

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Much of what has been said about the relationship between patients, relatives, and general practitioners is also true in the context of the hospital clinic. There are, however, several practical points that should be borne in mind. Aim to arrive at least ten minutes before the appointment time or, if parking is likely to be difficult, even earlier. If transport has been arranged by the hospital make sure that you are ready a good quarter of an hour before the time that the ambulance or car is due. It is very likely that you will have to wait for some time both before seeing the doctor and while some of the assessment is taking place, although you will be involved in quite a lot of this yourself. It is important therefore to take something to occupy yourself and if possible something that will occupy your relative with dementia. It is also a good idea to make sure you know where the toilets are and if you have to make use of them, let the nurse in charge of the waiting area know where you are going, and that you won’t be long. If you have to leave your relative in the waiting area, make sure that the nurse knows that he or she will be unattended, particularly if wandering is a problem. If your appointment is near a mealtime, ask whether there is a cafeteria for patients in the hospital or take sandwiches. It is better to do this than risk going without a meal. Make sure that the clothes your relative is wearing are easy to take off as he or she will probably need to be examined fully.

Remember that the staff at the clinic are there to help you. It may well be more difficult to talk to them than it is to your own general practitioner whom you know better and whom you see in relatively familiar surroundings. Even if the doctors, nurses, and others seem busy and hurried, remember that you have come a long way to see them, probably at great inconvenience to yourself and possibly others, and that it is important that you leave the clinic with a clear idea of the present position and what is going to happen next. After all, if you return home and find that one of your most pressing questions hasn’t been answered, it won’t be as easy to find out the answer as if you had only to repeat a visit to the general practitioner’s surgery.

Despite being well-organized, many people nevertheless discover when they arrive home that they have forgotten something that was said or have forgotten to mention something. Don’t worry about this! There are two courses of action that you can take. One is to make an appointment to see the family doctor and ask him whether he could answer the question for you or find out the answer. The other approach, possibly the better of the two, is to write a letter to the specialist explaining the position and putting the question again.

I would like to stress again that although the staff in hospital clinics may well seem more difficult to approach, either because they are less familiar than the local general practitioner or because they seem exceptionally busy, it is important that you take this opportunity of finding out the answers to your questions. Don’t be intimidated by them. As long as you ask your questions in a courteous and friendly manner, you will most likely be treated with consideration.

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Many people suffer from hardening of the arteries, including those of the brain, as they grow older. This means that the wall of the blood vessels thickens and narrows, causing a slowing down of the blood flow. It is, however, not this narrowing that causes the dementia, but a complete blockage causing the death of brain cells. Many people live with narrowed arteries for twenty or thirty years without any effect on their intellect; it is only a sudden, complete blockage that causes a stroke and an accumulation of these blockages that leads to MID. In many cases disease in the cardiovascular system elsewhere — outside the head — has resulted in small particles or clots travelling along the arterial system to a small artery in the brain that they then block, depriving that part of the brain of its blood supply with the resulting death of cells. This therefore is the sudden blocking off of small arteries referred to above whereas arteriosclerosis, when it occurs, blocks off arteries very slowly and may take years to cause significant narrowing of a blood vessel. It is not therefore always arteriosclerosis in the brain itself that causes the problems, but changes in the blood vessels elsewhere in the body, especially those between the heart and the top of the neck. Further causes of small strokes are discussed later.

Infarcts in the brain look similar, irrespective of the way in which they are caused. When they have been present for a long time there is often a small hole as the body’s natural processes remove the dead tissue. This hole usually fills up with fluid. Where this hasn’t happened there is usually a patch of softened material. Examining the brain with the naked eye can usually reveal all of these changes. Looking down the microscope will confirm that the microscopic changes that one expects to be associated with a stroke are also present.

If enough tissue is destroyed, there will be a reduction in brain size and weight with enlargement of the ventricles inside the brain and wasting of the ridges on the brain’s surface.

As one might expect, the severity of the dementia parallels the number of areas of the brain that have been destroyed. It has been suggested that dementia only occurs after a certain amount of brain tissue has died and this threshold has been estimated to be approximately 50 ml — the equivalent of ten teaspoonfuls. In many cases, however, we come across people who have multiple infarct dementia, but in whom there is less than 50 ml of dead brain tissue. Whether or not a person develops dementia seems to depend not only upon the total amount of brain tissue that has been lost, but also upon the site of the strokes. Some brain structures are more important than others in this respect.

Smoking

It is now well established that people who smoke cigarettes are more likely to have a stroke than non-smokers and it has even been suggested that about a third of strokes or similar episodes may be caused by cigarettes. There is, however, very little specific evidence to link smoking with dementia as opposed to paralysis of the limbs or face. Nevertheless because there is no doubt about the effects of smoking on the blood vessels, it makes sense to cut down or preferably to cease smoking altogether if there is any evidence of even a single stroke, whether this is affecting mental function or the limbs.

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Like so many other conditions that mainly affect older people, there always seem to be more elderly women who are affected by these illnesses than men. This is probably a reflection of the fact that in general women live longer than men, the average woman of sixty-five having a reasonable chance of living into her early eighties whereas most men of this age have a life expectancy of approximately thirteen years — into their late seventies. The situation isn’t quite as simple as this, however, because there is a suggestion that women with Alzheimer’s disease, the most common cause of dementia, tend to live longer than men with Alzheimer’s disease. There is no obvious reason for this, but it may be that female demented patients are fitter than the men. Some of this difference in life expectancy may be a result of the earlier habits of the men who are now old, since men used to drink and smoke far more than women. It will be interesting to see whether contemporary changes in these habits will even out the difference in the length of life expected by normal old men and women, and those with a dementing illness.

There is no unequivocal evidence that dementia strikes any particular social class or professional group more than others. Certain types of illness that cause dementia occur more frequently in certain groups; people who drink too much alcohol are more likely to have dementia, caused either by the brain damage that results from the excess drinking or because of the associated vitamin deficiencies that many alcoholics suffer from. However, as the commonest cause of dementia is Alzheimer’s disease which does not show a particular affinity for any specific group of people, dementia in general would appear to affect men and women in roughly equal measure and not to be associated with any other particular sub-group. The socio-economic group to which a person with dementia belongs does, however, have one important effect upon the progression of the illness, since those from lower socio-economic groups are more likely to be admitted to hospital or an alternative institution for prolonged periods of care and for the management of intercurrent illness.

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