The Common Neurological Diseases in the Elderly are Dementia,Delirium,Parkinson’s disease,Parkinsonism syndromes
Dementia is a neurological disorder (brain disease) where the brain gradually shrinks and looses several aspects of its function. Most commonly it is associated with gradual loss of memory, but then other aspects of brain function like speech, reasoning and judgement, executive functions like driving and cooking all gradually deteriorate.
Types of Dementia
Alzheimer’s disease: Alzheimer’s disease is the most well known and commonest of the dementia syndromes. It accounts for approximately (60 – 80) % of all dementias worldwide. A variant of Alzheimer’s disease begins in early age (before 70 years of age) and often is runs in families. Deposition of a protein called beta amyloid in the brain tissue, or disorganised protein fibres called neurofibrillary tangles are thought to be responsible for development of this disease. Alzheimer’s disease causes death and loss of nerve cell in important areas of brain made of grey matter, which is very important for intelligent brain function.
Vascular dementia: This kind of dementia develops with reduced blood flow in the brain. The blood vessels of brain may be clogged with clots or cholesterol deposits leading to gradual development of this disease. Patients with this kind of dementia also frequently have damaged areas of brain from previous Strokes or Bleedings into brain.
Lewy Body Dementia: This form of dementia develops due to deposition of an abnormal protein called Lewy Body in important areas of brain. Along with the common dementia symptoms of memory impairment & confusion this form of dementia is often associated with visual hallucinations (seeing objects and creatures which are not there), stiffness and slowness of body and shaking of limbs.
Parkinson’s disease associated dementia: In this form of dementia patients first develop Parkinson’ Disease with hallmark signs of stiffness and shaking of limbs and slowness in initiating any movement. Typically the dementia symptoms of deteriorating brain function and confusion develop late in the disease, at least 2 years after diagnosis. This dementia is also associated with deposition of Lewy bodies in brain and is often thought to be a variant of Lewy body dementia.
Frontotemporal dementia or Niemann/Pick’s disease: This form of dementia also causes nerve loss in important grey matter areas of brain similar to Alzheimer’s disease, but targets two specific areas of brain called frontal and temporal lobes. Symptoms commonly include abnormal social behaviour, personality changes and speech impairment which may finally render a patient completely unable to speak.
Post Delirium cognitive impairment: Delirium commonly develops as a sudden confusion in the elderly person unrelated to any primary brain disorder. Often infections, drugs, dehydration and other disorders of the body cause confusion in the elderly person. This will resolve in the vast majority (90 – 95%); however in 5 – 10% of patients the confusion from delirium does not improve and continues to worsen gradually with time.
Other causes: many patients especially the older ones beyond 80 years have more than one cause contributing to their dementia. These are called Mixed dementias. Cumulative and gradual damage to brain from Chronic alcoholism (Korsakoff’s syndrome) and recurrent head injury (common in boxers and footballers) can also cause dementia. Rare conditions called Prion diseases (infections of brain with foreign virus like proteins) can cause Creutzfeldt-Jakob disease which may present as atypical aggressive dementia syndrome.
Age: Age seems to be the greatest risk factor for developing dementia. This is a disease that is very rare below 60 years of age but gathers increasing numbers as patients go above 80 years. Some researchers believe that dementia is not a disease but represents normal aging and deterioration of brain function; in essence if we all lived long enough then all of us will develop dementia at some point of time.
Family history: This does NOT mean that if a person has dementia then their children will develop dementiaHowever certain forms of dementia like early onset Alzheimer’s disease (before 70 years of age) tend to run in families. If a parent or sibling has Alzheimer’s disease then the risk of a person developing the same is thought to be around 10 – 30%. Researchers have also found a particular gene called APO E4. About 50% of patients with this gene develop Alzheimer’s disease by age 90; thus showing that other unknown factors are also responsible. At present patients cannot be tested for the presence of this gene unless they are involved in any research study.
Vascular risk factors: Smoking, diabetes, blood pressure and high cholesterol are thought to be risk factors for developing vascular dementia.
Lifestyle factors: People with higher education, better social skills remain more engaged mentally and this seems to have a protective element.
Symptoms of Dementia
The hallmark of a dementia syndrome is the slow onset of symptoms and a very gradual decline. Also the patient with dementia in the early and middle stages of the disease remains physically well. In comparison the other commonest cause of confusion in the elderly patient, delirium, develops suddenly and often has a fluctuating course; the patient with delirium remains physically unwell also.
Dementia represents a gradual decline in global brain function across many areas including speech, memory, language, reasoning, judgment etc. The symptoms with each form of dementia are often slightly different but this may only be recognisable to skilled healthcare providers who have experience working with people with dementia. Sometimes family members notice changes but mistakenly blame them on old age.
Some mild non specific forgetfulness and slowness to learn and process new information can occur with old age, but they should never impact on the normal day to day functioning of a person. Some patients with such mild memory problems are labelled as Mild cognitive Impairment (MCI). A minority of these patients develop dementia with time and needs close monitoring. Treatment of patients with a diagnosis of MCI with dementia drugs DO NOT improve them, neither reduces the risk of developing dementia in future.
Early changes: The earliest symptoms of dementia are gradual and subtle. Many people and their families first notice difficulty remembering recent events or information (short term memory loss). Others can include the following.
Confusion (gradual onset)
Difficulties with language, like not finding the right word or not understanding speech of others
Difficulty with concentration and reasoning
Problems with executive function or complex tasks (driving, banking, cooking etc.)
Getting lost in familiar places
Late changes: As dementia progresses the symptoms gradually worsen and often include behavioural and personality changes. The physical well being of the patient also starts to decline gradually with increasing frequency of infections. Physical symptoms like appetite and weight loss and incontinence mark advanced stages of the disease.
Increased anger, hostility, and aggressive behaviour; alternatively some people become very passive
Hallucinations and/or delusions
Needing help with basic tasks (eating, bathing, dressing)
Incontinence (leaking urine or faeces without knowing)
The speed at which symptoms develop and decline vary in different persons. In the majority of cases the disease reaches advanced stages by 7 years from diagnosis. Most people with dementia do not die from the disease itself, but instead from a secondary illness such as pneumonia or urinary infection.
Mental Tests: There are several tests available to test a person’s memory and functioning of brain. They test various actions of the brain like memory, analytical skills, naming, recognising objects, speech formation and complex multitasking. Common tests include Abbreviated Mental Score (AMT, a 10 point score), MMSE (a 30 point score) and MOCA (a 30 point score). Below are links to a few of these tests.
MRI Brain: If dementia is suspected then some form of brain scan needs to be done to rule out any structural problem (i.e. tumours) in the brain. It can sometimes help in finding the type of dementia the patient has, but not always. The diagnosis of dementia is not based on brain scan. It is made on the basis of history and mental tests.
Blood tests: Certain vitamin deficiencies, commonly Vitamin B12 and Folic acid deficiencies may contribute and exaggerate symptoms of deficiency. Thyroid hormone deficiencies can also exaggerate symptoms of dementia.
EEG: This is a test measuring electric impulses and transmission in the brain. It involves putting electrodes on the head and measuring electrical activity. This is a common test used in diagnosis of epilepsy, but also has some value in investigating dementia.
Lumbar Puncture: In this test the doctor puts a needle in the back between the vertebral bones to obtain some fluid. This fluid is called the Cerebrospinal Fluid (CSF) and flows around the brain and spine. Analysis of this fluid for abnormal cells and proteins can sometimes provide important information on the type of dementia.
Acetylcholine esterase inhibitors: Acetylcholine is a chemical substance that acts to transfer information between brain cells, a neurotransmitter in medical terms. Certain theories suggest that the level of Acetylcholine is lower in patients with dementia. These medicines increase the level of Acetylcholine in the brain by stopping the breakdown of this substance. There are three medicine called Donepezil, Galantamine and Rivastigmine available in this group. Rivastigmine is also available as a patch and therefore more suitable for a patient who is experiencing swallowing problems with dementia.
This treatment is effective only in Alzheimer’s dementia and Dementia of Lewy body. This unfortunately does not offer any benefit in other forms of dementia. It is also important to note that these medicines DO NOT CURE dementia. They either improve the symptoms slightly or most importantly slow down the worsening which is otherwise inevitable in a patient with dementia.
Memantine: This is a unique medicine which acts through a different mechanism than the Acetylcholine esterase inhibitors. Memantine acts on another substance called glutamate which also acts as a chemical messenger in brain. Common side effects include dizziness and drowsiness. This medicine is again effective in Alzheimer’s dementia and Dementia of Lewy Body only.
Blood pressure and cholesterol control: These are often tried in managing vascular dementia. While these measures are obviously good for the general well being of a patient and protects their heart and brain, it is not well known whether they have any effect in slowing down vascular dementia.
Management of Complications of Dementia
Behavioural disturbances: These are very common symptoms in patients with dementia. These include a variety of symptoms ranging from depression, lethargy and apathy to anxiety, agitation and verbal or physical aggression. They are very difficult to control and often very frustrating for family members. The traditional dementia treatments described above like Acetylcholine esterase inhibitors and more commonly memantine may have some effect on these symptoms but are generally not the most effective. Generally distraction techniques by either speaking to them or using songs or lights are effective. If medicine usage is absolutely necessary then a trial of antipsychotic medication (Quetiapine, Promazine etc) can be given. These medicines should not be used continuously beyond 12 months and their use should be regularly reviewed. They increase the risk of sudden death from heart conditions and stroke. A medicine called Trazodone is also effective to certain extent.
Swallowing: Many patients with dementia experience difficulty with swallowing. In fact all patients are expected to experience difficulty with swallowing at some stage. In the early stages modification of food and drink to use thicker consistency fluids like soups and mashed diet may help.
With advancing dementia food and drink often starts to go into lungs causing complications like pneumonia. This suggests that the dementia is coming to the end stages and putting in artificial methods of feeding by inserting tubes through nose or directly into stomach does not help. Normal hand feeding by keeping the patient upright to reduce the risk of food going down to lungs is still the safest method.
Continence: Patients with advanced dementia develop incontinence of urine and stool. It is important for carers giving nursing to these patients to clean this regularly and protect the skin with ointments to prevent developing painful ulcers in these areas. Putting a catheter (tube in bladder) can help to protect the skin from urine, but increases risks of urine infection.
Life with Dementia
Maintaining Health: This includes both physical and mental health. Dementia is a process of deterioration and it is expected that functions will deteriorate. However with correct planning patients will be able to maintain their independence and function for a long time. Hence it is useful for such patients to get regular check up and take medicines regularly. Light physical exercise like walking helps. Playing games like crosswords, chess, card games which involve working the mind is extremely helpful. Regularly reading books and seeing photos of yesteryears are also thought to preserve brain function for longer.
Driving: This is a difficult issue in dementia patients as there is no clear guideline or a test to say when driving is not anymore advisable. Dementia being a progressive illness at some point all patients will be at risk if they continue to drive. This is a decision that has to be taken jointly by the doctor along with the patient and his or her family.
Medication: Dementia patients will often get confused with there medication and may not take them, or take too many. A family member or care giver must monitor this regularly as it is important for their well being that they take the correct medication in the right manner.
Cooking: As dementia involves the patient being forgetful and often having reduced attention span, cooking can be quite dangerous for these patients. Just like driving there is no definite test to say when a patient should stop and therefore a difficult decision. The patient should be regularly supervised during activities involving gas cooking. The decision to stop cooking should be taken jointly between the doctor and the patient or his or her family if there are concerns arising from such supervisions.
Family members and Caregivers for patients with dementia
Dementia is debilitating and can impose an enormous burden on patients and their families. People with dementia become less able to care for themselves as the condition progresses. Some tips that may help their families to cope include the following:
Be patient when responding to repetitive questions, behaviours, or statements.
Try not to argue or confront persons with dementia when they express mistaken ideas or facts. Gently remind them of the inaccuracy. If they continue to believe in the mistaken ideas, change the subject or distract them in some way. Continuing to argue or confrontation may make the patient aggressive or agitated.
Write down daily instructions for them to follow. Write down instructions for usual tasks (ie, the telephone, microwave, etc).
Establish night routines to manage behavioural problems, which are often worst at night. Leave a night light on in the person's bedroom.
Avoid major changes to the home environment.
Employ safety measures in the home, such as locks on medicine cabinets, keep furniture in the same place to prevent falls.
Speak slowly, present only one idea at a time, and be patient when waiting for responses.
Encourage physical activity and exercise. A daily walk can help prevent physical decline and improve behavioural problems.
The content for Delirium,Parkinson’s disease and Parkinsonism syndromes will be added soon.