Dementia is often viewed as a disease of the mind, an illness that erases treasured memories but leaves the body intact.
But dementia is a physical illness, too — a progressive, terminal disease that shuts down the body as it attacks the brain. Although the early stages can last for years, the life expectancy of a patient with advanced dementia is similar to that of a patient with advanced cancer.
But dementia is a physical illness, too — a progressive, terminal disease that shuts down the body as it attacks the brain. Although the early stages can last for years, the life expectancy of a patient with advanced dementia is similar to that of a patient with advanced cancer.
Also called: Senility
Dementia is a word for a group of symptoms caused by disorders that affect the brain. It is not a specific disease. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there.
Memory loss is a common symptom of dementia. However, memory loss by itself does not mean you have dementia. People with dementia have serious problems with two or more brain functions, such as memory and language.
The lack of understanding about the physical toll of dementia means that many patients near the end of life are subjected to aggressive treatments that would never be considered with another terminal illness. People with advanced dementia are often given dialysis and put on ventilators; they may even get preventive care that cannot possibly help them, like colonoscopies and drugs for osteoporosis or high cholesterol.
“You can go to an intensive-care unit in most places,” said Dr. Greg A. Sachs, chief of general internal medicine and geriatrics at Indiana University School of Medicine, “and you’ll find people with dementia getting very aggressive treatment.”
The continued focus on treatment to prolong life often means that pain relief is inadequate, and symptoms like confusion and anxiety are worsened. A new study suggests that family members would be far less likely to subject their loved ones to such treatment if they had a better understanding of dementia as progressive, debilitating illness that ultimately shuts down the body after years of mental deterioration.
Dementia causes many problems for the person who has it and for the person's family. Many of the problems are caused by memory loss. Some common signs of dementia are listed below. Not everyone who has dementia will have all of these signs.
- Recent memory loss. All of us forget things for a while and then remember them later. People with dementia often forget things, but they never remember them. They might ask you the same question over and over, each time forgetting that you've already given them the answer. They won't even remember that they already asked the question.
- Difficulty performing familiar tasks. People who have dementia might cook a meal but forget to serve it. They might even forget that they cooked it.
- Problems with language. People who have dementia may forget simple words or use the wrong words. This makes it hard to understand what they want.
- Time and place disorientation. People who have dementia may get lost on their own street. They may forget how they got to a certain place and how to get back home.
- Poor judgment. Even a person who doesn't have dementia might get distracted. But people who have dementia can forget simple things, like forgetting to put on a coat before going out in cold weather.
- Problems with abstract thinking. Anybody might have trouble balancing a checkbook, but people who have dementia may forget what the numbers are and what has to be done with them.
- Misplacing things. People who have dementia may put things in the wrong places. They might put an iron in the freezer or a wristwatch in the sugar bowl. Then they can't find these things later.
- Changes in mood. Everyone is moody at times, but people with dementia may have fast mood swings, going from calm to tears to anger in a few minutes.
- Personality changes. People who have dementia may have drastic changes in personality. They might become irritable, suspicious or fearful.
- Loss of initiative. People who have dementia may become passive. They might not want to go places or see other people.
During the last three months of life, 41 percent of the patients received at least one “burdensome” treatment, like transport to the emergency room, hospitalization, feeding tubes or intravenous treatments. Advanced dementia patients are particularly prone to infections because of incontinence, risk of bedsores, a depressed immune response and inability to report symptoms.
When the investigators looked more deeply into the reasons for treatment decisions, they discovered stark differences based on what family members knew about dementia. When they understood its progressive and terminal nature, only 27 percent of the patients received aggressive care. For family members who did not understand the disease, the figure was 73 percent.
“When family members understood the clinical course of dementia and the poor prognosis, the patients were far less likely to undergo these distressing interventions,” said the study’s lead author, Dr. Susan L. Mitchell, senior scientist at the Institute for Aging Research of Hebrew SeniorLife in Boston. “Dementia is a terminal illness and needs to be recognized as such so these patients receive better palliative care.”
The study also found that pain control was often inadequate. One in four subjects were clearly suffering from pain, but that number may understate the problem, because the patients were unable to talk about their pain.
Dr. Sachs, at Indiana, notes that care for patients with dementia has changed very little in the past 30 years. As a teenager, he watched his grandmother decline from Alzheimer’s disease. During her final months, she was repeatedly treated for infections and put in restraints or sedated to control agitation.
“Seeing my grandmother in that state was so distressing that my mother eventually stopped taking the grandchildren to visit,” Dr. Sachs wrote last week in an editorial in The New England Journal of Medicine. “My grandmother had little in the way of comfort or company toward the end. In my medical training, I learned how my grandmother’s final months were typical for people dying from dementia.”
A 2005 report from the Alzheimer’s Association showed troubling trends in care at the end of life. In a sweeping review of the medical literature, the investigators found that 71 percent of nursing home residents with advanced dementia died within six months of admission, yet only 11 percent were referred to hospice care, which focuses on comfort rather than active treatment.
Simply transferring a dementia patient from the nursing home to a hospital can lead to confusion, falls or a decline in eating — which in turn, often leads to further aggressive treatment.
Geriatricians say a large part of the problem is that the patients are unable to make their wishes known. In the absence of a living will, family members often struggle with guilt and are afraid to stop aggressive treatment because they do not want to be seen as abandoning a loved one in mental decline.
Dr. Sachs says doctors need to spend more time explaining the prognosis for advanced dementia, making it clear that palliative care does not mean less care.
“We’re not talking about aggressive care versus no care,” he said. “Palliative care is aggressive and attentive and focused on symptom management and support of the patient and family. It’s not any less excellent care.”
http://bulletin.aarp.org/yourhealth/diseases/articles/well_treating_dementia_but_overlooking_its_physical_toll.html
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