Understanding dementia
- Part 2 -

Dr Meesha Haorongbam *

3. Dementia with Lewy bodies (LBD)- It is a commonly misdiagnosed type of dementia which accounts for 10-15% dementias in autopsy. It has a prevalence of around 0.7% in population. A very simplified description of LBD is that it looks like a combination of Parkinson's disease (stiffness or rigidity, postural instability, gait difficulty) and Alzheimer's (cognitive decline).

LBD usually presents with attention deficits, the inability to judge spatial orientation of objects and lines in space (e.g. difficulty navigating in their homes or even moving out of a bed or chair), visual hallucinations (which are usually not upsetting to the person), anxiety and sleep disturbances.

The differences in cognitive profile between LBD and Alzheimer's are partially quantitative, and overlap increases with disease progression. It, therefore, comes as no surprise that many with LBD are misdiagnosed with Alzheimer. Compared to other forms of dementia, memory and verbal skills are better preserved and serious deterioration occurs only in the later stage.

Cognitive fluctuation is the hallmark of this disease. They are often described as episodes of behavioural confusion, inattention, excessive sleep, and incoherent speech alternating with episodes of lucidity and capable task performance.

4. Frontotemporal Dementia (FTD)- This is a less common type of dementia. It occurs due to loss of nerve cells in the frontal and temporal lobes of the brain i.e., the area behind your forehead and the regions behind your ears on either side, respectively.

These are the areas responsible for behaviour, personality, and production and comprehension of speech. So defects in these areas will lead to defects in the above mentioned actions.

There are three main types of FTD and therefore variations in presenting symptoms, but some of the common symptoms are-
a. Decreased motor skills
b. Increased sleepiness
c. Excessive craving for alcohol and food especially sweet foods
d. Decreased empathy
e. Rigid and inflexible thinking and impaired judgment
f. Bizarre somatic complaints
g. Repetitive or compulsive behaviour
h. Loss of insight into personal and social conducts
i. Change in personal and social conducts. Person may lack initiative, seem unconcerned, and neglect domestic, financial and occupational responsibilities.
j. Individual may show lack of emotional response or he/she may be inappropriately jovial.

Next comes the important issue of management. As much as we would like to believe otherwise, there is currently no cure for dementia.

Yes, reversible dementia such as those caused by intoxicants or nutritional deficiencies can be "reversed" as its name imply. Even though numerous studies are underway to halt the progress of dementia, it is unlikely that there will a single treatment effective for all the types of dementia.

Drug therapies do play an important role in retarding the progress of dementia though there will, of course, be some limitations. Drugs are also useful in managing the accompanying behavioural and biological symptoms such as sleep disturbance, hallucinations, aggression, depression etc. Non-pharmacological management will form the main stay treatment modality for dementia. Examples are:

1. Environmental interventions. E.g. installing bars and grips, removing pointed and sharp object from the individual's immediate surroundings, keeping the rooms well lit and well ventilated etc

2. Structured activities- There is immediate and short term memory loss in dementia while long term memory is relatively intact. A structured daily routine such as setting a fixed time for sleep, meals, bathing, extracurricular activities etc will make it easier for the individual to go about with his/her daily activities.

3. Communication- It isn't always possible to understand what patients with dementia are attempting to communicate. This makes it necessary to deduce needs from past behaviour. Questions beginning with "why" are to be avoided as far as possible as this requires a response that people with dementia are unable to provide.

General principles for communicating with such people include: identifying oneself and addressing the person by the names one usually use for them, using short words and simple sentences, asking one question at a time, giving adequate time for a response, repeating when necessary, speaking slowly and enunciating clearly, and accompanying speech with clarifying or reinforcing gestures. As verbal language deteriorates, non-verbal communication becomes more important.

4. Sensory enhancement- Sensory loss found in almost all elderly people is exaggerated in people with dementia. Hence there is need for sensory enhancement through music, massages and other media.

5. Social contact- This is one of the most important measures. Allow people with dementia to reminisce and tell stories about themselves. Help them interact with and care for a pet. Allow them to go for social events such as weddings. Help them review photo albums or personal memorabilia. Encourage long distance relatives to video-chat with them regularly.

6. Miscellaneous- Light therapy, hearing aids, measures to reduce discomfort and pain due to various reasons such as arthritis, bed sores, urinary tract infections, prolonged immobility etc.

If you know a family member or anyone with dementia, it is important to remember that:
1) Even though the person is struggling with memory, concentration and planning, they are the same person and deserve every bit of respect and dignity as anyone else.
2) Everyone experiences dementia differently.
3) Helping the person stay positive will benefit you too.
4) Encourage the person to stay socially active. Take them for walks, shopping, religious events etc
5) Make sure that they look after their health. Ensure a balanced diet, regular exercise, proper sleep habits, regular dental/eyesight/hearing check ups etc
6) Be a realistic caregiver. Set achievable goals. Always be realistic about the course of the disease.
7) Plan for the future. Plan for the inevitable outcome.
8) Accept help. Taking care of someone with dementia is a physically as well as emotionally daunting task. You will frequently be overwhelmed with emotions as the disease progress. There is nothing selfish in taking out some time for yourself.

There is still plenty of truth in the old adage that goes "prevention is better than cure". While risk factors such as age, gender, heredity etc cannot be changed, we do have control over other risk factors.

Like, keeping our blood pressure, blood sugar and blood cholesterol in check, reducing or even better avoiding alcohol, giving up smoking etc.

There are 6 main pillars for preventing dementia.
1. Regular exercise- Incorporate atleast 150 hours of exercise in a week
2. Social engagement- Being socially active does wonders for the brain. Volunteer in some group, join a gym, keep in touch with your neighbours.
3. Diet- It goes without saying that a healthy diet is very essential to lead a healthy life. Stock up on fruits and vegetables, cut down sugar, consume Omega 3-fatty acid-rich food.
4. Mental stimulation- Learn something new. Pick up a new hobby. Regularly solve sudokus, puzzles or riddles. Fine tune a previously learned skill. Do something once in a while with your non-dominant hand.
5. Get adequate sleep. Maintain proper sleep hygiene.
6. Stress management- Stress is contradictory to a healthy life. Get involved in pleasurable leisure activities. Practice relaxation techniques such as yoga, progressive muscle relaxation, meditation. Breathe!

Dementia robs people of their independence and the very memories that make them who they are. It affects not only the patient but their caregivers and the society at large. The economic impact of the disease is massive. We may not personally know a person with dementia but it is affecting tons of people around us. Only a collective effort can help tackle this global health crisis.

"Alzheimer's is the cleverest thief, because she not only steal from you, but she steals the very thing you need to remember what's been stolen"- Jarod Kintz