Dementia

Dementia is a term that describes the loss of cognitive function, usually because of damaged brain cells. It includes memory loss and at least one of the following: difficulty with language, impaired movement, and inability to plan and initiate appropriate behaviors socially or at work. People with dementia may not be able to care for themselves by getting dressed or eating; they may have trouble balancing their checkbook and may get lost in familiar settings.

Behavior and Sleep Problems

People with dementia often have certain problems when it gets dark at the end of the day and into the night. This problem is called "sundowning." The problems that get worse include increased confusion, anxiety, agitation, confusion, and not being able to get to sleep and stay asleep.

Tips for Behavior and Sleep Problems
Having a daily routine may help. Calmly reassuring and giving cues to orient the person who has dementia is also helpful in the evening and closer to bedtime. Try to keep them going to bed at the same time every night. 

Doing calm activities at the end of the day and before bedtime may help the person with dementia sleep better at night. If they are active during the day, these calm activities can make them tired and more able to sleep. 

Avoid loud noises and activity in the home at night, so the person does not wake up once they are asleep. 

Do NOT restrain a person with dementia when they are in bed. If you are using a hospital bed that has guard rails in the home, putting the rails up may help keep the person from wandering at night. 

Always talk with the doctor before giving the patient store-bought sleep medicines. Many sleep aids can make confusion worse. 

If the person with dementia has hallucinations (sees things that are not there):

  • Try to decrease the stimulation around them. Avoid things with bright colors or bold patterns.
  • Make sure there is enough light so that there are no shadows in the room. But do not make rooms so bright that there is a glare.
  • Avoid movies or television shows that are violent or action-packed.
  • Take the person to places where they can move around and exercise during the day, such as shopping malls.

If the person who has dementia has an angry outburst, try not to touch or restrain them. Touch or restrain them only if you need to for safety. Instead, try to stay calm and distract them during outbursts. Do not take their behavior personally. 

Try to prevent the person with dementia from getting hurt if they start wandering.

Causes

Most types of dementia are nonreversible (degenerative). Nonreversible means the changes in the brain that are causing the dementia cannot be stopped or turned back. Alzheimer's disease is the most common type of dementia. 

Lewy body disease is a leading cause of dementia in elderly adults. People with this condition have abnormal protein structures in certain areas of the brain. 

Dementia also can be due to many small strokes. This is called vascular dementia. 

The following medical conditions also can lead to dementia:

  • Parkinson's disease
  • Multiple sclerosis
  • Huntington's disease
  • Pick's disease
  • Progressive supranuclear palsy
  • Infections that can affect the brain, such as HIV/AIDS and Lyme disease

Some causes of dementia may be stopped or reversed if they are found soon enough, including:

  • Brain tumors
  • Changes in blood sugar, sodium, and calcium levels (see: Dementia due to metabolic causes)
  • Low vitamin B12 levels
  • Normal pressure hydrocephalus
  • Use of certain medications, including cimetadine and some cholesterol-lowering medications
  • Chronic alcohol abuse

Dementia usually occurs in older age. It is rare in people under age 60. The risk for dementia increases as a person gets older. 

Complications

Complications depend on the cause of the dementia, but may include the following:

  • Abuse by an overstressed caregiver
  • Increased infections anywhere in the body
  • Loss of ability to function or care for self
  • Loss of ability to interact
  • Reduced lifespan
  • Side effects of medications used to treat the disorder

When to Contact a Medical Professional 
Call your health care provider if:

  • Dementia develops or a sudden change in mental status occurs
  • The condition of a person with dementia gets worse
  • You are unable to care for a person with dementia at home

Daily Care

People who have dementia may have trouble with language and communication, eating, memory, and basic care for themselves. 

Help with Memory Loss
People who have early memory loss can give themselves reminders to help them function each day. Some of these are:

  • Ask the person you are talking with to repeat what they said, or repeat what they said to yourself 1 or 2 times. This will help you remember it better.
  • Write down your appointments and other activities in a planner book or calendar. Keep it in an obvious place, such as beside your bed.
  • Post messages around your home where you will see them, such as the bathroom mirror, next to the coffee pot, or on the phone.
  • Keep a list of important phone numbers next to every phone.
  • Have clocks and calendars around the house so that you stay oriented to time and the date.
  • Label important items.
  • Develop habits and routines that are easy to follow.

Eating and Nutrition
Some people who have dementia may refuse food or not eat enough to stay healthy. Some tips that may help are:

  • Help the person get enough exercise. Ask them to go outside with you for a walk.
  • Have someone the patient likes, such as a friend or relative, prepare and serve them food.
  • Reduce distractions around the eating area, such as the radio or TV.
  • Do not give them foods that are too hot or too cold.
  • Give the patient finger foods if they have problems using utensils.
  • Try different foods. It is common for people who have dementia to have decreased smell and taste, and this will affect their enjoyment of food.
  • In later stages of dementia, the person may have trouble chewing or swallowing. Talk with their doctor about a proper diet. At some point, the patient may need a diet of only liquid or soft foods, to prevent choking.

Tips for Talking with Someone with Dementia

  • Keep distractions and noise down:
  • Turn off the radio or TV.
  • Close the curtains.
  • Move to a quieter room.
  • To avoid surprising the patient, try to make eye contact before touching or speaking to them.
  • Use simple words and sentences, and speak slowly. Speak in a quiet voice. Talking loudly, as if the person is hard of hearing, will not help. Repeat your words, if needed. Use names and places the person knows. Try not to use pronouns, such as "he," "she," and "them." This can confuse someone with dementia. Tell them when you are going to change the subject.
  • Talk to people who have dementia as an adult. Do not make them feel as if they are a child. Do not pretend to understand them if you do not.

Ask questions in a way that they can answer with a simple "yes" or "no." Give the person clear choices, and a visual cue, such as pointing to something, if possible. Do not give them too many options. 

When giving instructions:

  • Break down instructions into small and simple steps.
  • Allow time for the person to understand.
  • If they get frustrated, consider changing to another activity.
  • Try to get them talking about something they enjoy. Many people with dementia like to talk about the past, and many can remember the distant past better than recent events Even if they remember something wrong, do not insist on correcting them.

Personal Grooming
People with dementia may need help with personal care and grooming. 

Their bathroom should be nearby and easy to find. Consider leaving the bathroom door open, so they can see it. Suggest they visit the bathroom several times a day. 

Make sure their bathroom is warm. Get them undergarments made for urine or stool leakage. Make sure they are cleaned well after going to the bathroom. Be gentle when helping. Try to respect their dignity. 

Make sure the bathroom is safe. Common safety devices are:

  • A tub or shower seat
  • Handrails
  • Antiskid mats
  • Do not let them use razors with blades. Electric razors are best for shaving. Remind the patient to brush their teeth at least 2 times a day.

Clothing Tips:

  • A person with dementia should have clothing that is easy to put on and take off.
  • Do not give them too many choices about what to wear.
  • Velcro is much easier than buttons and zippers to use. If they still wear clothes with buttons and zippers, they should be in the front.
  • Get them pullover clothes and slip on shoes, especially as their dementia gets worse.

Dementia & Driving

If your loved one has dementia, deciding when they can no longer drive is a difficult decision. They may react in different ways:

  • They may be aware they are having problems, and they may be relieved to stop driving.
  • They may feel their independence is being taken away.

Signs that Driving May No Longer Be Safe 
People with signs of dementia should have regular driving tests. Even if they pass a driving test, they should be retested in 6 months. 

If your loved one resists you getting involved in their driving, get help from their doctor, lawyer, or other family members. 

Even before you see driving problems in someone with dementia, look for these signs that they may be at risk for driving badly:

  • Forgetting recent events
  • Mood swings or getting angry more easily
  • Problems doing more than one task at a time
  • Problems judging distance
  • Having trouble making decisions and solving problems
  • Becoming confused more easily

Signs that driving may be getting more dangerous are:

  • Getting lost on familiar roads
  • Reacting more slowly in traffic
  • Driving too slowly or stopping for no reason
  • Not noticing traffic signs or not paying attention to them
  • Taking chances on the road
  • Drifting into other lanes
  • Getting more agitated in traffic
  • Getting scrapes or dents on the car
  • Having trouble parking

Steps to Take 
It may help to set limits when driving problems start. Stay off busy roads, or do not drive at times of the day when traffic is heaviest. 

Do not drive when the weather is bad. Do not drive long distances. Drive only on roads the patient is used to. 

Caregivers should try to lessen the person’s need to drive without making them feel isolated. Have someone deliver groceries, meals, or prescriptions to their home.

Find a barber or hairdresser who will make home visits. Arrange for family and friends to visit and take them out for a few hours at a time. 

Plan other ways to get your loved one places. Family members or friends, buses, taxis, and senior transportation services may be possibilities. 

As danger to others or to your loved one increases, you may need to prevent to them from being able to use the car. Some ways to do this are:

  • Hiding the keys
  • Leaving out car keys that will not start the car
  • Disabling the car so it will not start
  • Selling the car
  • Storing the car away from the home

Exams and Tests

Dementia can often be diagnosed with a history and physical exam by a skilled doctor or nurse. A health care provider will take a history, do a physical exam (including a neurological exam), and perform some tests of mental function called a mental status examination. 

The health care provider may order tests to help determine whether other problems could be causing dementia or making it worse. These conditions include:

  • Thyroid disease
  • Vitamin deficiency
  • Brain tumor
  • Intoxication from medications
  • Chronic infection
  • Anemia
  • Severe depression

The following tests and procedures may be done:

  • B12 level
  • Blood ammonia levels
  • Blood chemistry (chem-20)
  • Blood gas analysis
  • Cerebrospinal fluid (CSF) analysis
  • Drug or alcohol levels (toxicology screen)
  • Tests for exposure to metals such as lead or arsenic
  • Electroencephalograph (EEG)
  • Glucose test
  • Head CT
  • Liver function tests
  • Mental status test
  • MRI of head
  • Serum calcium
  • Serum electrolytes
  • Thyroid function tests
  • Thyroid stimulating hormone level
  • Urinalysis

Keeping safe at home

Safety Tips for the Home
Wandering can be a serious problem in people who have more advanced dementia.

These tips may help prevent wandering:

  • Place alarms on all doors and windows that will sound if the doors are opened.
  • Place a "Stop" sign on doors to the outside.
  • Keep car keys out of sight.

To prevent harm when someone with dementia does wander:

  • Have the patient wear an identification bracelet or necklace with their name, address, and phone number.
  • Tell neighbors and others in the area that the person who has dementia may wander. Ask them to call you or to help them get home.
  • Fence and close off any areas that may be dangerous, such as a stairwell or deck, or a hot tub or swimming pool.
  • Consider giving the person a GPS device or a cell phone (which will have a GPS locator embedded in it).
  • Inspect the person’s house, and remove or reduce hazards for tripping and falling. 

Other home safety tips include:

  • Do not leave a person who has advanced dementia alone in the home.
  • Lower the temperature of the hot water tank. Remove or lock up cleaning products and other items that may be poisonous.
  • Make sure the kitchen is safe.
  • Remove knobs on the stove when it is not in use.
  • Lock up sharp objects.

Remove, or store in locked areas:

  • All medicines, including the patient’s medicines and any over-the-counter drugs and supplements
  • All alcohol
  • All guns. Separate ammunition from the weapons.

Prevention

Most causes of dementia are not preventable. 

You can reduce the risk of vascular dementia, which is caused by a series of small strokes, by quitting smoking and controlling high blood pressure and diabetes. Eating a low-fat diet and exercising regularly may also reduce the risk of vascular dementia. 

Signs & Symptoms

Dementia symptoms include difficulty with many areas of mental function, including:

  • Language
  • Memory
  • Perception
  • Emotional behavior or personality
  • Cognitive skills (such as calculation, abstract thinking, or judgment)
  • Dementia usually first appears as forgetfulness.

Mild cognitive impairment is the stage between normal forgetfulness due to aging and the development of dementia. People with MCI have mild problems with thinking and memory that do not interfere with everyday activities. They are often aware of the forgetfulness. Not everyone with MCI develops dementia. 

Symptoms of MCI include:

  • Forgetting recent events or conversations
  • Difficulty performing more than one task at a time
  • Difficulty solving problems
  • Taking longer to perform more difficult mental activities

The early symptoms of dementia can include:

  • Language problems, such as trouble finding the name of familiar objects
  • Misplacing items
  • Getting lost on familiar routes
  • Personality changes and loss of social skills
  • Losing interest in things you previously enjoyed, flat mood
  • Difficulty performing tasks that take some thought, but that used to come easily, such as balancing a checkbook, playing games (such as bridge), and learning new information or routines

As the dementia becomes worse, symptoms are more obvious and interfere with the ability to take care of yourself. The symptoms may include:

  • Forgetting details about current events
  • Forgetting events in your own life history, losing awareness of who you are
  • Change in sleep patterns, often waking up at night
  • More difficulty reading or writing
  • Poor judgment and loss of ability to recognize danger
  • Using the wrong word, not pronouncing words correctly, speaking in confusing sentences
  • Withdrawing from social contact
  • Having hallucinations, arguments, striking out, and violent behavior
  • Having delusions, depression, agitation
  • Difficulty doing basic tasks, such as preparing meals, choosing proper clothing, or driving

People with severe dementia can no longer:

  • Understand language
  • Recognize family members
  • Perform basic activities of daily living, such as eating, dressing, and bathing

Other symptoms that may occur with dementia:

  • Incontinence
  • Swallowing problems

Treatment

The goal of treatment is to control the symptoms of dementia. Treatment depends on the condition causing the dementia. Treatment option may include:

  • Some people may need to stay in the hospital for a short time.
  • Stopping or changing medications that make confusion worse may improve brain function.
  • There is growing evidence that some kinds of mental exercises can help dementia.

Treating conditions that can lead to confusion often greatly improve mental functioning. Such conditions include:

  • Anemia
  • Decreased oxygen (hypoxia)
  • Depression
  • Heart failure
  • Infections
  • Nutritional disorders
  • Thyroid disorders

Medications may be needed to control behavior problems caused by a loss of judgment, increased impulsivity and confusion. Possible medications include:

  • Antipsychotics (haloperidol, risperdal, olanzapine)
  • Mood stabilizers (fluoxetine, imipramine, citalopram)
  • Serotonin-affecting drugs (trazodone, buspirone)
  • Stimulants (methylphenidate)

Certain drugs may be used to slow the rate at which symptoms worsen. The benefit from these drugs is often small, and patients and their families may not always notice much of a change.

  • Donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne, formerly called Reminyl)
  • Memantine (Namenda)

A person's eyes and ears should be checked regularly. Hearing aids, glasses, or cataract surgery may be needed. 

Psychotherapy or group therapy usually does not help because it may cause more confusion. 

What to ask your doctor

  • Are there ways that I can help someone with their memory around the home? 
  • How should I talk with someone who is losing or has lost their memory? 
  • What type of words should I use? 
  • What is the best way to ask them questions? 
  • What is the best way to give instructions to someone with memory loss?
  • How can I help someone with dressing? Are some clothes or shoes easier? 
  • What is the best way to react when the person I am caring for becomes confused, hard to manage, or does not sleep well? 
  • What can I do to help calm the person down? 
  • Are there activities that are more likely to agitate them? 
  • Can I make changes around the home that will help keep the person calmer?
  • What should I do if the person I'm caring for wanders around? 
  • How can I keep them safe when they do wander? 
  • Are there ways to keep them from leaving the home?
  • How can I keep the person I'm caring for from hurting themselves around the house? 
  • What should I hide? 
  • Are there changes in the bathroom or kitchen I should make?
  • What are the signs that driving is becoming unsafe? 
  • How often should this person have a driving evaluation? 
  • What are the ways I can lessen the need for driving? 
  • What are the steps to take if the person I am caring for refuses to stop driving?
  • What diet should I give this person?

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