Dementia - Memory Loss
Dementia is a disorder of the brain. It involves the loss of memory and other mental functions. It can result from many different causes and can vary in its severity from patient to patient. Many people are familiar only with Alzheimer’s disease, a degenerative dementia that accounts for half the cases and are unaware of other treatable causes of dementia. Even in cases in which the underlying cause may not be readily treatable, careful management can support and extend the quality of life for the patient, family, and friends.
Dementia may include:
- Loss of memory, particularly recent memory.
- Impairment of intellectual functions severe enough to interfere with a person’s job, social life, or both.
- Change in personality.
- Behavioral changes such as delusion, hallucination, or depression.
- Impairment of judgment.
Generally there is an organic cause for dementia, but, in many patients, this can be difficult to identify. There is usually no impairment of consciousness. The affected person remains alert. Most dementia is progressive, but the speed of progression may be highly variable from person to person. Often it is very slow.
Evaluation by a physician is important to uncover the reversible components of the patient’s dementia. In addition, every effort should be made to help the patient achieve optimal physical health. The added burden of poorly controlled high blood pressure, diabetes, or other chronic diseases may worsen the difficulties related to dementia.
Important Points in Treatment
The goal of treatment is to provide a satisfactory quality of life for the patient and caregiver. Variation in patients and in resources available to deal with individual patient’s problems prevents making strict rules.
- Encourage physical activity. Respect the patient’s physical limits, but remember that lack of activity and exercise can be as detrimental to the quality of life as too much activity or exercise. Each increment of loss of fitness due to neglect of exercise has a negative effect on the patient’s ability to maintain the activities of daily living.
- Encourage good nutrition. Often this becomes a balancing act between adequate nutrition and optimal nutrition. Carefully structured diets are good only to the extent that they are eaten. The patient will eventually require help with eating.
- Help the patient with insomnia maintain a normal relationship to the environment. Bright lights during the day and avoidance of naps are helpful. The body has a normal day/night rhythm that needs to be reinforced.
- Avoid challenging the limits of intellectual ability. Stick to tasks that are within the current intellectual capabilities of the patient. To maintain the current level of intellectual function, the individual must use these capabilities. Do not isolate the patient from activities of daily living. Attempt to motivate participation in everyday activities, but remember the patient’s limits. Careful use of memory aids and routines can help even intellectually impaired patients remain active in daily affairs.
- Manage the patient’s environment to avoid confrontation and frustration. Simplify activities; use memory aids and safety engineering. Adjust the surroundings for ease of getting around. Encourage use of lights.
- Identify complications and potential complications in the management of daily living. Particularly important complications are wandering, incontinence, depression, agitation, and aggressiveness.
- Regularly participate in the reevaluation of the patient’s general health. Effective management requires changes as the dementia progresses.
- Seek help from social services to identify community resources appropriate for the patient’s level of need.
- Seek counseling to help with legal, social, and ethical decisions regarding management choices.
Many of the problems associated with dementia such as delusion, insomnia, agitation, or depression are treatable with medication. Careful evaluation by your physician is essential to select the most appropriate drug.
Few drugs are directly useful in the management of dementia, but several new drugs are available to help slow the progression of dementia. These include tacrine (Cognex), ergoloid mesylates (Hydergine), and donepezil (Aricept). Tacrine does not reverse changes in memory function that are already present, but it does slow the progression of these changes. Therefore, it is useful as a long-term adjuvant in the care of patients with senile dementia.
Tacrine should be taken on an empty stomach. It takes several weeks or more for a full effect. It does not seem to benefit all patients. Often there must be a trial period to see if it will be effective in a given patient. The drug has significant side effects. These include alteration of the effects of other drugs and the possibility of some injury to the liver. Donepezil is a new drug similar to tacrine in its effects.
Ergoloid mesylate may provide slight improvement in thinking, but it is helpful in only a few patients. Selection of patients to receive any of these drugs requires discussion between the caregiver and the patient’s physician.
Many drugs that are properly given for coincident but unrelated conditions can worsen dementia or complicate its management. A careful, written medication history available to all physicians involved in the patient’s care, including all drugs (prescription and nonprescription), is the best defense against medicationinduced complications.
Notify Our Office If
- There is any suspicion of infection or injury. Patients with impaired mentation are susceptible to infection and injury without manifesting the usual or expected complaints.
- A patient taking tacrine or donepezil complains of nausea, headache, or sore muscles.
- A patient taking tacrine or donepezil has vomiting, diarrhea, or difficulty keeping balance.
- Abrupt changes in mental status occur. Many other diseases do not necessarily present with typical symptoms, but most will produce some change in status, particularly mental status.
Incontinence and Dementia
Dementia is a loss of intellectual function. Impaired mental status may sometimes result in the development of urinary incontinence. This happens because patients who lose their mental awareness may release their bladder contents when they feel the urge. The severity of the incontinence generally corresponds with the severity of the dementia.
Other complicating factors may occur. A number of the drugs used to treat the dementia may produce incontinence as a side effect. Infection of the urinary tract causes frequent urges to urinate and may be an underlying cause of the incontinence. Sometimes incontinence occurs because of nighttime confusion or wandering that prevents access to the toilet.
Important Points in Treatment
If you are caring for an incontinent person, you face a difficult challenge. Frequently, incontinence becomes a reason to refer a patient to a nursing home. Your patience will be tested. Partial continence is possible in less severely demented patients, which improves the quality of life of the caregiver as well as of the patient. The patient’s physician will try to control the factors that may be causing the incontinence.
Your patient needs ready access to toilet facilities. The bedroom should have direct access to the bathroom, there should be a night-light in the bedroom, and a soft light should remain on in the bathroom. If the patient is unsteady physically, you can have grab bars and an elevated toilet seat installed. If you cannot make these bedroom and bathroom arrangements, a bedside commode is an effective substitute.
You can partially control the patient’s urinary output by controlling the times when the patient drinks fluids. For instance, you can minimize incontinence while the patient is sleeping by having the patient avoid drinking large amounts for 2 hours before bedtime. This does not mean fluid restriction, because adequate daily fluid intake is important for good health. Small amounts of fluid help to keep the mouth comfortably moist. In addition, the patient may have to take medication right before bedtime.
Special garments (continence garments) are available from commercial suppliers. Incontinence pads also are available to protect furniture and bedding. Careful selection of the right garment will allow the patient to have a comfortable social life without embarrassment despite episodes of incontinence. The right garment and pad will also make your life as a caregiver easier and less frustrating.
For men, a number of urine collection (drainage) appliances are available to control incontinence. These also have a role in the care of demented men. The physician may occasionally insert a catheter to aid in emptying the bladder. Catheters carry a risk of infection, however, and a catheter by itself is not proper treatment of incontinence.
Notify Our Office If
- The patient has any evidence of urinary tract infection. Patients with incontinence are susceptible to infection of the urinary tract. Urinary tract infection can cause fever, chills, a burning sensation on urination, frequent urination, cloudy urine, or bloody urine. Sometimes with incontinence, the patient may have an infection of the urinary tract but may not have any of these symptoms.
- The patient has any change in urinary habits. A change indicates something is wrong, whether it is an infection, another illness, or a side effect of the patient’s medication.
- The patient has any evidence of blood in the urine.
Seniors do not have an exclusive option on forgetfulness, but one common feature of the aging process is the failing of short-term memory. This impairment may range in severity from simple forgetfulness to severe amnesia. In all but the most severely impaired, the use of memory aids can help to compensate for much of the memory impairment.
Medications and Treatments
Remembering to take medication in the proper dose and at the proper time is important for the prevention and management of illness. Missed doses are a common problem in patients who do not have any unusual memory impairment, and they become a greater problem when memory begins to fail. Repeating a dose because of failure to remember that it has already been taken also is a problem. These difficulties increase with multiple drugs and the treatment of several diseases, a common occurrence in elderly patients.
The use of a simple dosing system can help the patient follow a medication schedule. For the patient:
- Start by gathering all the medications, both prescription and nonprescription, that you take regularly. Also gather the medications that you take only as needed.
- On a clean sheet of paper, list all of the medications or treatments across the top, using a separate column for each medication or treatment.
- In the left margin, list each time for a medication or treatment, from the time of the first morning dose or treatment through the time of the last dose or treatment of the day.
- Complete the chart by marking in each column the dose or number of pills taken for each medication at each time. When complete, you will have a daily medication schedule.
- The next step is to try to simplify the medication schedule by grouping as many of the medications and treatments into the same time slot as possible. Be sure to seek the help of your physician when doing this. Some medications are ineffective or even dangerous when taken together. Take a copy of this schedule on all visits to your physician. It will help the physician understand your current medication program and to ensure that any new medications or treatments are added at the best times.
For many patients, posting the simplified medication schedule in the kitchen or bathroom serves as a sufficient reminder. However, some patients need additional help to keep track of what has actually been taken each day. They should do the following:
- Obtain one empty pill vial from your pharmacist for each time slot where there is a medication to take or a treatment to perform.
- Label the vial with the medicine(s) to be taken and the time it is to be taken.
- Each morning, fill the vials with their appropriate pills. During the day, you can tell at a glance if the dose has been taken or missed.
- Use an alarm clock or timer as a reminder to take the next dose. Select a clock with an alarm that is simple to set and change. As one vial is emptied, reset the alarm for the time on the next vial.
- When a treatment is involved, place a small square of cardboard with the name of the treatment in the vial as a reminder.
A caregiver can make a daily visit to fill the vials to ensure optimum compliance even when the patient may be alone for much of the day. This helps promote independence in day care without any sacrifice in treatment. When the patient is to be away from home, the proper vials should be carried in pocket or purse to ensure that medications are taken at the proper times.
Many varieties of vials and boxes designed to remind the patient to take medication at the proper time and dose can be purchased. Some hold a week’s rather than a day’s supply. Others have timers and alarms as reminders. Avoid selecting a gadget that is too complex to use easily and successfully. Multiple tiny hinged doors, receptacles too small to admit a finger, and complex alarms are self-defeating.
Activities of Daily Living
Grooming and food preparation are examples of activities of daily living that involve multiple tasks, any one of which can be easily forgotten. Who among us has not at some time forgotten to shave when grooming or to put in the vanilla when baking a cake? Any momentary distraction while at morning toilette or at the kitchen counter is all that is needed. Slight memory impairment worsens this problem. Regular use of memory aids can protect against these mishaps.
Each step in daily grooming usually involves a special item: toothbrush, razor, comb, brush, lipstick, and so on. Storing these items together as a group in a drawer or on a tray, separate from other clutter, converts them into a memory aid. Begin your grooming by setting out each of the required grooming aids on a countertop or any other convenient surface in the bathroom. As each item is used, replace it in the storage drawer or on the storage tray. Everything will be used. Nothing will be forgotten. It may be necessary for the grooming aids to be set out by a caregiver for later use by the patient. This "jump-starts" the grooming process yet preserves the patient’s independence and involvement in personal care.
The key to success is the use of an uncluttered environment both for storage and for laying out the daily grooming aids. Clutter inevitably leads to confusion, which in turn defeats the purpose of the memory aid. A similar strategy is applicable to other activities of daily living, such as washing dishes, paying bills, and following recipes. Most serial or sorting tasks can be handled in this manner. The keys are to:
- Use an uncluttered work area.
- Set out all items to be used.
- Return items to storage once they are used.
Appointments and Schedules
Each year there is a new wrinkle in ways to record appointments and schedules. Most of these products are for an office or business setting; outside a business environment, many of them lose their cleverness. None of them work unless they are used, and this means that most products are user-friendly. The two keys for a successful memory aid for appointments and schedules are:
- It must be simple to update.
- It must be accessible.
Most patients rely on a note on a slip of paper or an appointment card from their physician or dentist as their appointment reminder. These are variously hung on bulletin boards or on the front of the refrigerator. Loose papers get lost, some on the floor, others in the clutter of past appointment reminders not yet discarded. Replace these with a planner.
A full-year planner can be found in most office supply stores. This is a form of calendar that places all 12 months on a single large page with a place to write in messages for each day in the year. They are usually 2 X 3 feet and are available in paper or plastic. An erasable felt-tip marker is used with the plastic type. Planners cost from $5 to $10. Ten dollars is not an inconsiderable sum, but it is far less than the cost of one missed appointment.
The key to the successful use of a planner is its location. It must be where you see it first thing every morning. It is best if it is reachable from the telephone. The kitchen is the usual choice, but lifestyles vary, and another room may be more appropriate for some. You can quickly tell if the location is proper by noting whether you enter appointments on the calendar as you make them. If you do not, the location is wrong. Mark out each day as it is completed with a marker. You will never be at a loss concerning what you must do next.