Understanding Dementia

By Dr. Raymond Zakhari

Dementia is one of the most common conditions that I deal with in my private practice. I wanted to provide a summary of the most common types of dementia. How to go about reducing the burden on the patient and loved ones. There are many kinds of dementia, but I am going to focus on 3 types.

The most common form of dementia is Alzheimer’s disease. Two other types of dementia include vascular dementia and Lewy Bodies dementia. Distinguishing between types of dementia can be difficult. It can get easier to distinguish the type of dementia as the condition declines.

Dementia is a neurological disorder that ranges in severity. There are 5 phases of progressive worsening decline:

  1. Mild Cognitive Impairment: the person thinks slower than usual or appears distracted. There can be some mild forgetfulness, and impaired problem solving. Depression and anxiety can mirror these symptoms.
  2. The next level of severity is Mild Decline. The symptoms of Mild Decline Dementia include:
    • increased confusion
    • impaired concentration
    • increased distractibility
    • trouble making plans or decisions and communicating desires
    • more frequent episodes of slowed thinking
    • more frequent episodes of forgetfulness

This stage can last several years.

  1. The next level of decline is Moderate Decline. The symptoms of Moderate Decline will include:
    • difficulty in getting dressed
    • neglect of hygiene
    • forgetting to eat
    • forgetting to take medication
    • forgetting important appointments
    • forgetting key facts about personal life
    • bills go unpaid
    • the trash may not go out
    • they may wear the same clothes for a week or more
    • the dog may get overfed
    • there may be spoiling groceries in the refrigerator
  1. The next level of decline is Severe Decline. Severe Decline symptoms include:
    • needing a high level of care to the point of constant supervision
    • help in bathing/ changing
    • meal prep
    • using the bathroom

Other symptoms that may present in this stage include personality and behavior changes:

    • increased hostility
    • irritability
    • extreme flirtatiousness to the point of exhibitionism
    • emotional lability from laughing to crying for no reason

The brain at this point is at a very primitive stage of regression.

One of the most helpful strategies in dealing with someone with dementia is distraction. Other strategies include plying them with creature comforts such as favorite foods, music, scents, movies, old photos, and distraction. In this phase, do not take anything as a personal affront. They may tell you how horrible you were as a child. They may tell everyone you are abusing them. They may tell you they never liked your bratty kids. They may tell you your father was a horrible lover and they had an affair with his brother. They may tell you that you have a long lost sibling. The reason you cannot take these statements on face value is because they can be confabulations. The may mistake fantasy for reality. The may be telling you story of someone else’s life. They may be telling you the story of a TV show or movie. They may be combining all these scenarios.

  1. The final stage before death is the very severe decline. The very severe decline stage is a late stage. In this late stage of dementia the person needs around-the-clock care. They will lose interest in eating and drinking. They may no longer feel thirst or hunger. They will speak less, and appear more vacant. Eventually, they may stop communicating all together.

The problem with dementia is the rate of decline can vary. Meaning it can be a gradual decline over months to years. Or it can accelerate in the rate of decline seemingly out of the blue.

What are some symptoms to help distinguish the type of dementia?

  • Vascular dementia can have a characteristic step wise declining process. Meaning a plateau followed by a steep drop off in function as a result of a sharp increase in symptoms. Things will appear stable again, this will be the new lower functioning baseline. Then a steep drop again. This pattern is most common with vascular dementia. The problem is people can have more than one kind of dementia.
  • Alzheimer’s Dementia is the most common type. Patients with this type often have a vacant appearance. They become more forgetful, and struggle to find the right words.
  • Lewy Bodies dementia has many of the similar features of Alzheimer’s Dementia and Vascular Dementia. Some distinguishing symptoms include a movement disorder that looks like Parkinson’s Disease. Patient may show the following symptoms:
    • a shuffling gait
    • slow movement
    • hand tremor at rest
    • impaired physical balance and repeated falls
    • loss of coordination
    • smaller handwriting
    • reduced facial expression
    • difficulty swallowing, increased drooling
    • weak voice
    • reduced eye blinking

In about 80% of cases people with Lewy Bodies dementia they may also have visual hallucinations of little people. Unlike Alzheimer’s Dementia people with Lewy body may not have forgetfulness. They will show poor judgement, confusion about time and place, and trouble with language and numbers.

People with dementia will often over-estimate their abilities and be very resistant to help. The most common reason they end up in skilled nursing facilities is due to falling. Frequent trips to the emergency room lead to frequent hospital admissions. Frequent hospital admissions accelerate decline.

What can one do if they suspect they or a loved one has dementia?

  1. Get a comprehensive physical exam and psychiatric evaluation. The goal is diagnosis and treat any underlying conditions than can mimic symptoms of dementia such as urinary tract infection, constipation, dehydration, depression, anxiety or excessive medications.
  2. Make sure the goals of care are in place. In NYS we have a form to help guide called the Medical Orders of Life Sustaining Treatment. The goal is make a plan of care that your loved ones are aware of that spells out do you want a natural death or do you want everything done to try and save you from feeding tubes, to ventilators. Your primary care provider can help you make these decisions. In some states a living will can suffice. The best option is to appoint a health care proxy who knows your wishes and nuances who can make decisions for you should you not be able to decide.
  3. Assuming the diagnosis of dementia is made stop telling the patient things like remember you used to like , or quizzing the patient as it is not helpful and often frustrating because they may be aware that they are losing their memory.

Communicating with someone who has dementia:

  • Be gracious give the answer, remind calmly, limit choices as they can be overwhelming, remember to distract
  • Establish and maintain a routine, novelty can be disorienting and frustrating. Anticipate their needs.
  • Remain reassuring and calm as they can pick up your anxious energy, frustration, and irritability. Ensure their comfort from pain.
  • Make sure they are eating, drinking, urinating, and having consistent bowel movements at least once every 2 days.
  • Make sure you are doing full frontal face to face communication of no more than 3 feet away and speak slowly. Make sure you have their attention.
  • Make everything simple to do in small steps.
  • Agree, never argue
  • Divert, do not try to use logic or reason (it is impaired)
  • Distract, do not shame them
  • Reassure, do not lecture
  • Reminisce with them do not say remember (because no, they do not)
  • Simply repeat, do not say I told you already
  • Do things they can do, to avoid saying things like you cannot
  • Ask them, do not demand of them
  • Encourage, do not condescend
  • Do validate their feelings.
  • Orient them frequently Hi Mom, Dad, Frank, or Jill, it is Monday Morning the date is . . . and time for Breakfast.

I hope you have found this post useful, please share it with someone who may find it useful.