Anand Lal was around 63 years old, when his son found his father had become extremely forgetful. Over the past one year, he had been unable to manage the family business and committed frequent errors in taking even simple decisions, resulting in financial losses. Though a very articulate person, of late he had been struggling to communicate adequately, his speech at times meaningless. He had become extremely irritable and aggressive and had to be stopped from attending office. The family could not comprehend how a man they so loved and respected for his business acumen, competency and pleasant personality could turn into such a confused, helpless and irritable human being.
The above case exemplifies a major mental health and neurological problem affecting the aged—dementia. This affects usually those above 65 years (senile dementia) but at times even younger persons which is referred to as presenile dementia, also known more popularly as Alzheimer’s Disease (AD). The number of persons suffering from it is directly proportionate to increasing age and is as high as about 30 per cent in those aged 85 and above.
As we grow older, our ability to perform intellectually slows down as a result of brain atrophy related to normal ageing. However, this process can be slowed if the person continues to remain alert and intellectually active. In those suffering from dementia, however, there is a progressive degeneration of brain tissues that leads to a gradual decline in intellectual and cognitive functioning including memory, language, constructional abilities and judgment. In fact, there is total personality deterioration. All this occurs in a normal conscious state, which implies the person is not delirious or in a semi-conscious state. The process is generally gradual and decline occurs over a period of one-10 years. Death is almost always inevitable in most cases but usually from other illnesses or neglect.
STAGES OF DEMENTIA
The initial stage of dementia is often difficult to recognise and symptoms include emotional, social and intellectual aspects. Though their development is gradual in some instances the dementia can be abruptly unmasked during a period of stress in the patient’s life.
Emotional changes can often be the first clue. This includes loss of interest in work and family, or increased irritability. They may complain of minor aches and pains and feel that ‘something is wrong’. Yet others steadfastly deny any problem at all throughout, even when showing obvious signs of deterioration. Depression about one’s failing capacity and anxiety about the future may constitute early features of the illness. They may feel restless and there is a tendency to wander incessantly. They may become obstinate, rigid and egocentric. Memory difficulty is the most common complaint which is characterised by an inability of learning new information or rather what is known as recent memory. This further disintegrates later as whole segments of experience are blotted out and the person becomes increasingly disoriented in time and place. He may recall only remote, early life memories and slowly starts forgetting names of familiar people, including his or her own family members.
It is only in the middle and later stages of the illness when all the above changes become more pronounced and the person is less able to manage his personal, social and occupational affairs that the alarm bells ring. Memory shows gross deterioration with the person becoming acutely disoriented and confused, failing to recognise even people close to them. Speech becomes meaningless, repetitive with difficulty in finding words and a failure to recognise common objects such as a pen, clock etc by name. Simple tasks become monumental to execute and he or she is unable to carry out even simple activities of daily living, such as brushing, bathing, toilet hygiene, wearing clothes, combing hair, self feeding.
In the later stages, the person may become sleepless and restless and tends to wander about aimlessly and can even lose their way around familiar places. Useless, repetitive behaviour such as picking, folding or manipulating objects in their hands may be seen. Personality changes may be bizarre and dramatic with anger or violent outbursts or paranoid behaviour. Some may become devoid of any emotions. They may gradually lose touch with reality and turn apathetic and mute or muttering to themselves or babbling. At this stage they may show typical psychotic features, making their problem obvious to everyone.
In the final stages the person turns negative, feeble, helpless, has difficulty in walking, cannot care for self and also be incontinent for bladder as well as bowels. Seizure, falls and accidents may also occur. Death usually results from pneumonia, urinary infection or septic infection and usually within five years from the onset of the disease.
As the exact nature and causes of senile dementia and AD are still being unravelled and treatment is in experimental stages, caring for these persons is a challenge for all concerned—the patient, family, doctors and society. We will deal with the causes and management of dementia in the next issue of India Empire.