Dementia: An Elderly People’s Nightmare

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In 2020, over 12% of the population of Mauritius was 65 years and older and increasing at an average yearly rate of 3.25% (1). It is therefore important to consider ageing dynamics as a vital health issue of the Mauritian society. The growing prevalence of age-related disease such as Alzheimer and dementia in older people is becoming an alarming challenge not only for the sufferers but also for their families and carers. In 2015, dementia affected about 5% of the world’s elderly population and globally nearly 9.9 million people develop dementia each year (2). According to the World Health Organization data (2018), the estimated dementia prevalence in the Mauritius GBD region was 5.8% of the population (3) with 39 related deaths (4).

Age-related diseases, such as Alzheimer and Dementia have serious consequences on the overall health of older people and their economic dependence, and on the health systems and budgets, thus demanding greater funding and focus from the government and allied sources. The 2014 Observatory on Ageing report (5) found major gaps in the capacity of the current system to meet these needs, such as lack of specialized, tailored care and activities for those living with dementia, lack of awareness of dementia and Alzheimer’s among caregivers, lack of support for informal caregivers, and insufficient interaction between health professionals, management, and caregivers, with families not involved in the development of care plans. There is not enough NGOs developing and implementing an Action Plan on Dementia. I have no intention of playing politics regarding this important health issue. Rather, my focus is to build a psycho-social education platform for understanding Dementia and Alzheimer’s disease in elderly people. So, what is Dementia, and it’s causes?

Dementia is not the same as Alzheimer. It is a syndrome, not a disease. It is a term that describes a group of symptoms that impact negatively on a person’s memory, make communication difficult, restrict the performance of daily activities independently, and affect the brain’s function to the point of interfering with a person’s social life and capacity to work. Although dementia is more prevalent in people 65 years and over, it can also affect people in their 40s and 50s. Alzheimer’s on the other hand is a disease of the brain causing the brain cells to die, which gets worse with time and slowly causes impairment in memory, language and thought process. It is the most common type of dementia.

Early signs of Dementia usually begin with forgetfulness, whereupon people have difficulty keeping track of time, remembering people’s name and faces, remembering recent events, understanding what others are saying, expressing thoughts, making decisions, managing finances, lack of hygiene, and feeling lost in their familiar environment. Other common symptoms include confusion, withdrawal, and personality change. As their behaviour changes, depression and aggression can set in.

Common types of dementias are Alzheimer’s, Vascular, Lewybody, Fronto-temporal, CreutzfeldtJacob, Wernicke-Korsakoff syndrome, Normal Pressure Hydrocephalus, Huntington’s disease, and Mixed-Dementia. Dementia usually develops as we become older, and the brain cells start to degenerate. Other conditions that can cause dementia include HIV, stroke, traumatic brain injuries and depression. However, Alzheimer’s disease is usually the most prevalent cause of dementia ranging between 50-70% of cases.

Alzheimer’s disease can be caused by the build-up of amyloid plaques and neurofibrillary tangles in the brain, genetic mutations, and inclusions. Amyloid plaques are clumps of betaamyloid in the part of the brain that holds memory. The plaques disrupt communication between the nerve cells, that is disrupts the transfer of short-term memories into long-term memories. Neurofibrillary tangles are fibrous tangles of an abnormal protein called Tau which when altered gets the fibres twisted together resulting in the collapse of the neuron vessels. Genetic mutation is the early onset of Alzheimer’s disease developed in people as young as in their 30s and 40s. Inclusions are abnormal structures in the brain, made of various protein.

Lewy body dementia is caused by abnormal structures in the brain’s outer layer, called the cortex, which is responsible for our cognitive thoughts such as thinking, perceiving, producing, and understanding language. This disease affects the nerve cells that release essential neurotransmitters responsible for controlling our movement and coordination. It is common among people with Parkinson’s disease. Fronto-temporal dementia involves degeneration of the brain cells in the frontal and temporal lobes of the brain which controls our judgment, emotion, language, and personality. This disease causes significant changes in one’s behaviour and language. Vascular dementia can be caused by a condition that prevents blood flow to the brain. The brain acquires oxygen from the bloodstream, without which the brain cells die. One common type of vascular dementia is multi-infarct dementia which is caused by several small strokes in the brain, especially when it takes place in the left hemisphere of the brain and when it involves the hippocampus where our memory is stored. Creutzfeldt-Jacob disease usually appears in people 60 and over because of problems with the brain proteins or when in contact with brain or nerve tissue that carries a disease. Wernicke-Korsakoff syndrome is a brain disorder caused by a lack of vitamin B-1, leading to bleeding in the lower sections of the brain and causing physical symptoms like double vision and a loss of muscle coordination. People with Korsakoff syndrome experience problems with processing information, remembering things, and learning new skills. This syndrome can be due malnutrition or chronic infections. Alcoholism is the most common cause of the vitamin B-1 deficiency.

Normal Pressure Hydrocephalus (NPH) is caused from excess fluid in the brain’s ventricles, thus putting extra pressure on the brain. NPH can be caused from bleeding, brain tumour, infections, previous brain surgeries, resulting in forgetfulness, poor balance, frequent falls, loss of bowel and bladder control, changes in mood and depression. NHP can sometimes be cured with surgery. Huntington’s disease is a genetic condition that causes dementia and exists in both juvenile and adult life. This disease causes early breakdown of the brain’s nerve cells. Symptoms of Huntington’s disease include difficulty walking, jerking, and trouble swallowing. The dementia side of the symptoms include trouble speaking clearly, difficulty focusing on tasks and problems with impulse control. Mixed dementia is very common, where a person has more than one type of dementia such as a combination is vascular dementia and Alzheimer’s. The symptoms of mixed dementia can be memory disorientation first, behaviour and mood changes, difficulty speaking and walking.

All the above-mentioned conditions are caused by several risk factors, such as age, memory loss, Down syndrome, genes, and lifestyle changes such as alcohol and drug abuse, heavy smoking, heart conditions, poor diet, obesity, diabetes, and depression. Many causes of dementia are irreversible. However, if they are detected early and given appropriate treatment, they may be reversed. Some reversible conditions include nutritional deficiencies such as Vitamin B-1 linked to alcoholism, B-6, and B-12, poisoning, thyroid problems, lack of sugar in the bloodstream, lack of sodium or calcium, anaemia, effects of drugs, heart and lung problems, and infections such as Meningitis, syphilis, Lyme disease and AIDS, and lack of oxygen.

Treatments for dementia and Alzheimer’s overlap. Currently there is no cure for Alzheimer’s disease, but the symptoms of Alzheimer’s can be managed by medications such as antipsychotics to change behaviours, medication for memory loss, sleep changes, depression, and recourse to alternative medicine such as fish and coconut oil, and Mediterranean diet. Generally, people diagnosed with Alzheimer’s live for approximately four to eight years after diagnosis, while others can live for up to 20 years.

It is very important to provide people suffering from dementia with the right care. While we all have the best intention to look after our diagnosed family members and friends as carers and volunteers, sometimes the old strategies we use are not necessarily the best or just don’t work anymore. So, it is necessary to always look at innovative approaches and strategies as follows. First promote safety and trust. Help them to feel safe by speaking to them slowly and calmly, communicate with them at their level, reassure and acknowledge them all the time that they are safe, keep them informed, organise a routine for daily activities, teach them calming activities and reduce noises in their environment, especially when they are stressed. Do what you said but don’t overpromise.

Second, provide them with choice and control. Establish their needs before offering advice by asking them what will make them feel safer, provide choice and flexibility in their daily routine, engage them in happy activities they like, ask them to participate in activities, help them when they are confused and provide them with psychosocial education about dementia. Third, build on their existing skills and support. Help them to connect with others and focus on their strengths by educating and supporting families and carers, ask and provide them opportunities to talk about their feelings, always have someone present when they are distressed, support their use of skills, hobbies, and activities, engage them in group activities and provide them with grief and loss counselling from a trained professional. Fourth, help them to believe in recovery by generating hopes and focussing on goals. Finally, when they are angry and displaying aggression, keep calm, acknowledge their distress, reassure them their safety, respect their boundaries, ask them what help they need. Provide options, use simple language and visual cues, repeat important messages, talk to them in a safe environment and with a person they feel safe and trust, help them with distraction activities and calming strategies such as breathing (6).

The World Health Organisation (2020) recommends 12 strategies to reduce risk for cognitive decline (7): 1. Be physically active; 2. stop smoking; 3. eat a balanced diet, like the Mediterranean diet; 4. drink alcohol in moderation; 5. cognitive training; 6. be socially active; 7. look after your weight; 8. manage any hypertension; 9. manage any diabetes; 10. manage any cholesterol; 11. manage depression; and 12. look after your hearing and manage hearing loss (7).

While carers, and government and community organisations do their best to support you, it is also very important to understand what you can do for yourself from the time you notice changes in your cognitive process so that you can maintain your independence for as long as you can and enjoy life. Seek help by talking to your doctor and contacting dementia organisations as they provide a range of services to people with dementia and their families. Tell people close to you such as family and friends that you have dementia. You are the same person, except that you are experiencing a change in your brain condition like many other people. It is normal to feel upset, angry, and frustrated about the changes in your life and talking about these feelings can help. Join a dementia support group and share experiences and ideas with other sufferers for dealing with the condition. Manage memory lost by keeping and carrying a diary of im- portant things you need to remember such as your own and emergency telephone numbers, appointments, photos, and names of people close to you, your address, and places where you keep important things. For your security, wear a bracelet or necklace which is linked to a 24-hour emergency assistance service with all your personal details.

To conclude, currently there is no cure for most types of dementia. As such, it can have devastating impact on sufferers, and their family and friends. It is therefore vital to seek early and consistent treatment upon noticing any form of dementia. Besides medications, support from family, carers and friends, support services from home health aides, government and community organisations, incorporated dementia day centre infrastructure in government and NGO facilities for older people, assisted living facilities, and as a last resort nursing homes are essential for helping with and managing the conditions and dignity of dementia sufferers. On a philosophical and psychological note, you are not alone. Be strong .


References

1. World Data Atlas Mauritius Demographics (2011): Population 65 and over as a share of total population. 2. World Life Expectancy (2020): Alzheimer’s and Dementia in Mauritius. 3. World Health Organization (2018): WHO Provisional Dementia Observatory. Provisional Country Profile. 4. World health Organization (2017): Global action plan on the public health response to dementia 2017 – 2025 5. FP Analytics (2018). Mauritius: The 2018 Ageing Readiness and Competitiveness Report: Small Innovative Economics. 6. Phoenix Australia (2021). Understanding Dementia and Trauma in Aged Care

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