Dementia A WellBeing Special Report By Matthew Boylan 1 Dementia
Contents 1. What is dementia? Page 3 Causes Types of dementia Diagnosis What to expect 2. Prevention Page 7 Brain training Diet Pharmacological approach Complementary approach 3. Management of Dementia Page 13 2 Dementia
Dementia is a terrible illness. A person with dementia experiences a gradual decline in their abilities to think, remember and carry out their normal daily activities. They consequently require ever-increasing personal care and eventually become totally reliant upon their caregivers. Thus the symptoms and care requirements of dementia present major challenges not only for the person with dementia, but for their family and friends as well. These challenges are so great that even the closest relationships, between a parent and child or two people in a couple, are vulnerable to breaking down. The odds are increasing that you may be affected in some way by dementia. As we live longer lives, more and more Australians are experiencing some form of dementia. Alzheimer s Australia advise that about 200,000 Australians now have dementia. With about 54,000 new cases diagnosed every year, this number is expected to grow to 730,000 by 2050. Of course, we all want to live longer and the good news is that there are steps you can take to reduce the likelihood of you or someone else in your family developing dementia. At the very least you may be able to delay its onset. In addition, if dementia does unfortunately develop, there are measures you can take to help maintain your or your loved ones current quality of life. WHAT IS DEMENTIA? Dementia is a term used to describe a broad set of symptoms that occur due to brain disease. These symptoms include the loss of memory, intellect, rationality, social skills and normal emotional reactions. In dementia, these symptoms progressively become worse and cause increasing difficulties in carrying out everyday personal, social and work functions until the sufferer eventually becomes entirely dependent upon care. Although many people with dementia die first from other causes, advanced dementia will result in death. As you age it is natural to lose some of your cognitive abilities such as your ability to think, learn, remember, understand and judge. In normal ageing, however, these changes take place over decades; the changes due to dementia occur much faster, maybe over several months or just a few years. The changes in dementia are also more extensive. For example, in normal age-related short term memory loss an older person might forget part of a recent movie; someone with dementia might not even be able to remember sitting down to watch the movie. Most people think of Alzheimer s disease when they think of dementia. Although Alzheimer s disease is the major cause of dementia, accounting for about 60 per cent of dementia diagnoses, it is not only the cause. In fact, there are over 100 causes of dementia. There are, however, only another three major causes of dementia in addition to Alzheimer s: Vascular dementia, which causes about 20 per cent of cases; Dementia with Lewy bodies, which causes 10-15 per cent of dementia cases; and Fronto-temporal dementia, which may account for up to 10 per cent of cases. There may also be an overlap between these types of dementia. So let s have a more detailed look at these four main types of dementia. 3 Dementia
Major causes of dementia Alzheimer s disease Vascular dementia Dementia with Lewy bodies Fronto-temporal dementia Alzheimer s disease In Alzheimer s disease, insoluble deposits of a protein called beta-amyloid build up to form plaques called amyloid plaques. These plaques stick to the outside of nerve cells (neurons) in the brain, especially to those neurons dealing with memory and other cognitive functions. In addition, neurofibrillary tangles of other proteins called tau proteins form within the affected neurons. These changes prevent the neurons from communicating properly with each other and the affected cells eventually die. As more and more neurons are affected and die, increasing abilities and functions are lost. Vascular dementia Vascular dementia occurs when disease that affects blood vessels in the brain also affects the neurons and causes dementia. There are many different diseases affecting the brain s blood vessels that might result in dementia; strokes, thromboembolisms (blockage of a blood vessel due to a blood clot) or bleeding into or around the brain, may all result in dementia. About one-quarter to one-third of stroke victims will unfortunately experience later dementia. Dementia with Lewy bodies This relatively new classification of dementia has only been recognised as a distinct category of dementia for about 10 years. Lewy bodies are accumulations of a protein called alpha-synuclein. They accumulate within neurons where they interfere with the cells functions and ultimately cause the affected neurons to die. Fronto-temporal dementia This type of dementia is known by several different names, including Pick s disease. Like Alzheimer s disease, it is caused by an accumulation of abnormal tau protein in brain neurons. With this dementia, however, the abnormal accumulations occur in the frontal and temporal lobes of the brain. These areas control reasoning, judgment, insight, personality, social behaviour, speech, language and some aspects of memory. The damage to these neurons disrupts their functions, and ultimately the cells also die. 4 Dementia
Dementia with Lewy bodies Characteristics Of The Four Major Types Of Dementia Risk factors Main symptoms Disease Progression Alzheimer s Genetic factors Memory, language disease combined with and recognition additional factors problems occur first. including being Difficulties with coordination, aged over 65, mobility head injuries, a and sensory high fat diet, activities generally smoking, occur later. hypertension or diabetes. Vascular Genetic factors, Variable, being dementia combined with secondary to the additional factors nature of the blood such as cerebral vessel disease that vascular has caused the disease, dementia. Frontotemporal dementia hypertension or Type 2 Diabetes. Most common in the 50-85 age group, but no other known risk factors. No definite risk factors, but likely to be a strong genetic link. More common in younger people (from 35 years of age). Similar to Alzheimer s disease, but with greater fluctuations in the severity of symptoms and a greater likelihood of muscular & movement problems. There may be vivid hallucinations or dreams. Profound personality changes. Decline in social skills and personal hygiene. Disinhibited verbal, physical and sexual behaviour. Fluctuations between apathy and hyperactivity. Memory and language skills are initially preserved. Initially symptoms are subtle, but they progressively become worse and more incapacitating. After about 10 years the person enters a terminal phase of the illness. Sudden appearance following a cerebral vascular disease. Generally there is a pattern of sudden deterioration in symptoms followed by a period of stabilisation before another sharp decline. Quicker progression than Alzheimer s disease. This dementia generally lasts for about four to seven years before entering a terminal phase. Insidious development and gradual deterioration. Following diagnosis, a victim of this form of dementia has an average life expectancy of six to 12 years. 5 Dementia
Diagnosis is vital As people get older, they often notice changes in cognitive functions such as a deterioration in memory. These concerns are usually nothing more than a simple awareness of normal age-related cognitive changes. They may also be due to other treatable medical problems such as anxiety, depression, poor nutrition or the side-effects of medication. It is very important, therefore, that a medical diagnosis be obtained as soon as possible to allow any non-dementia condition to be treated. If the problem is indeed dementia, an early diagnosis will enable early access to support, information and medication. What to expect People with dementia experience differences in their condition from day to day, or even during a single day. One of the defining characteristics of dementia, however, is that it is a progressive condition. That is, the person s condition will, unfortunately, deteriorate over time. Dementia is often classified in three stages: early, middle and late. Although not all sufferers will have the same symptoms at the same stage, it is possible to gain an approximate understanding of what to expect by looking at the symptoms commonly present at each stage. Early dementia In the early stages of dementia, people are generally able to function independently in most areas of their lives, which makes early detection difficult. Any problems are simply put down to being over-tired or over-worked, or to old age. A key early indicator, however, is a noticeable impairment in short-term memory. Long-term memories tend to remain unaffected. Another common difficulty is being unable to find the right word for common, everyday objects. There may be subtle personality changes too. For example, a usually reserved person might start telling risque jokes, or an outgoing person might become reclusive. A person might start experiencing short, transient episodes of acute confusion. Other difficulties might include a difficulty in the day-to-day handling of money, a reduced ability to cope with change and an increasing tendency to be more self-centred. Moderate or Middle Stage dementia At this middle stage, the difficulties being experienced are more evident and disabling. The affected person will require some assistance to function in the community at a level near what they previously enjoyed. Memories of recent events are now poorly retained. Long-term memory remains less affected, though now there may be some confusion about the details of those long-term memories. Names of family members and friends, and the correct day or date, may be forgotten. A person may become lost on occasions and unable to find their way home. Alternatively, the sufferer may now start going on long walks. Personal hygiene standards also noticeably decline. Eating may start to be neglected. There may be odd behaviour such as inappropriate dressing or increased aggression. During this middle stage, a person with dementia becomes very aware of their declining cognition and ability to function properly. This gives rise to many psychological symptoms including delusions and depression. 6 Dementia
Advanced or Late Stage dementia By this stage the person is severely disabled and requires 24-hour care. Eventually people with late stage dementia spend at least some time in a nursing home. There is virtually no recall of recent events, and long-term memories have become vague and unreliable. There is little or no recognition of family and friends. Language skills are greatly affected. There is no ability to plan or organise activities. There is minimal insight into decision-making. Anger and distress increase. Self-care skills are lost, and the person generally requires assistance with eating, washing, bathing, dressing and going to the bathroom. There may be a loss of the co-ordination required to use a knife and fork, or difficulties in chewing and swallowing food. The person may also become listless and inactive. On the other hand, they can be restless, and wander aimlessly. Difficulties in walking will however eventually develop, and the person will ultimately be confined to a wheelchair. Many patients with dementia will pass away before becoming extremely debilitated due to severe dementia. Causes of death in these cases are illnesses such as pneumonia or cardiovascular disease. PREVENTING DEMENTIA There are no cures known at present for the four main types of dementia being discussed here, so prevention is critical. If the onset of dementia can be delayed by just five years, the number of people suffering dementia will be reduced by half. It is likely that dementia most commonly develops due to a combination of age, genetics and environmental factors. You cannot do anything about your genes but you can positively influence your environment so as to lessen the risks of developing dementia. Research has identified several environmental, lifestyle and dietary factors that are closely associated with the subsequent development of dementia. By restricting your exposure to these factors you can adopt lifestyle habits that are healthy for your brain; brain-healthy lifestyle habits may delay or prevent the onset of dementia, as well as providing other health benefits. Brain train: how to exercise your brain Starting with your children, encourage them to progress through formal education to the highest level that is realistic for them. Lower formal educational attainment is associated with an increased risk of developing dementia, in particular Alzheimer s disease. This may be due to a variety of reasons, but one hypothesis focuses on what is termed a person s brain reserve. The concept of a brain reserve is that your brain carries reserve neurons that it uses as a back-up in times of need, such as when there has been damage to the brain by disease or accident. Mental activity can enhance brain growth so people who undertake more study may be creating for themselves a larger brain reserve upon which to draw if they later develop dementia. This may result in a longer period before any incapacitating symptoms appear. 7 Dementia
The importance of mental activity does not end at childhood, however. It continues throughout life. Adults with hobbies that exercise their brain are two-and-a-half times less likely to develop Alzheimer s disease. The best mental activities for you and your family are those which are relatively complex, but also enjoyable. They should be fun, varied and undertaken on a regular basis. For older adults, it is especially important to enjoy some challenging mental activity every day. The enjoyment factor is important: activities which are boring, or which over-tax your abilities, may actually be detrimental to your mental health. So if you don t enjoy crosswords, but do enjoy following a complex knitting pattern, knit your brain a protective helmet! See the information box for other suggestions to keep your mind in shape. Brain exercises for you and your family Play mind games such as crosswords, puzzles, chess, draughts or cards. Read. Keep a diary, write letters. Learn new skills such as how to use a computer or play the guitar. Take a course, or learn a new language. Take up a hobby. Visit museums. Prepare meals that require some thought. Adapted from Alzheimer s Australia s booklet Mind Your Mind: A User s Guide to Dementia Risk Reduction. Body train for your brain The concept of brain reserve might also explain why physical trauma to the brain can increase a person s likelihood of later developing dementia. Always protect your head, for example by wearing a helmet when riding a bike, rollerblading or horse riding. Physical activity is also important for your brain s health. By increasing blood flow to the brain, physical exercise can assist mental function and prevent strokes and other vascular diseases. Exercise may also help prevent the death of brain cells. It has not yet been established that exercise will definitely protect against dementia, but a recent Australian study found that daily gardening was associated with a lower risk of later developing dementia. Daily walking was also found to be protective against dementia, but only for men, not women. Suitable exercise choices are nearly endless. As a general rule, remember that what is good for your heart is good for your brain. For example walk to the local shops or park instead of driving. Do some gardening for 30 to 45 minutes each day, walk three kilometres in 40 minutes, or swim laps in a pool for 20 minutes. Try for a minimum of 20 to 30 minutes of exercise every day. Anti-dementia diets Diet is always very important for protecting against disease. When it comes to dementia, eating fish at least once a week has been shown to reduce your risk of developing dementia by up to one-third. This might be due to the omega-3 fatty acids found in large quantities of 8 Dementia
several fish species. These omega-3 fatty acids most likely protect you against the development of vascular risk factors for Vascular dementia and Alzheimer s disease. While we re on fats, saturated fats, trans fatty acids and high levels of cholesterol have all been shown to increase the risk of developing dementia. So protection against dementia is another reason for you to avoid having too much of these unhealthy fats. There has been a lot of research conducted on the association between folic acid, vitamins B 6 and B 12, and homocysteine in the development of dementia. High levels of homocysteine have been linked to several disease states, including Alzheimer s and Vascular dementia. Folic acid and vitamins B 6 and B 12 are all important for the breakdown of homocysteine. Debate continues, however, as to whether or not homocysteine causes adverse health conditions, or is simply a by-product of the various disease processes. Regardless of the actual role of homocysteine, studies have shown that low levels of vitamin B 9, B 12 and folic acid are all linked with the subsequent development of reduced cognitive abilities and some forms of dementia. It is easy for your family to enjoy a diet rich in B vitamins. There are also many vitamin B supplements available in supermarkets and health food shops. Just remember, to be most effective, the B vitamins need to be taken as a group so don t just buy a single B vitamin supplement without also buying a multi-b vitamin supplement to go with it. There is some evidence that antioxidants, especially vitamins C and E, obtained from food may protect you against Alzheimer s disease. It is unlikely that foods rich in antioxidants will damage your brain, and as they have many other health benefits they should be a regular part of your family s diet. It is well known that drinking alcohol in excess can cause brain damage. Light to moderate drinking, on the other hand, especially of red wine, may protect against dementia. Alcohol intake is not suitable for everyone, though, and even small amounts of alcohol can cause increased confusion in those who have already developed dementia. Your Brain-Healthy Diet Have at least one or two fish meals a week. The best fish are salmon, tuna, mackerel, herring, trevally and sardines. Reduce your saturated fat intake. Choose only lean meats, low-fat products or those with no fat. Cut out refined, packaged and take-away meals that may be high in saturated or trans fats. Fish, liver and other organ meats, legumes, wheat germ, eggs, nuts, green leafy vegetables, cheese and milk are all good sources of vitamins B 6 and B 9 and/or folic acid. Eat foods rich in the antioxidants vitamins C and E. These include citrus fruits, capsicums, strawberries, watermelon, rockmelon, cabbage, cauliflower, broccoli, cold pressed vegetable oils, nuts, seeds, spinach, sweet potatoes, egg yolks, liver and dairy products. Green tea is also very rich in antioxidants. Eating plenty of fruit and vegetables will increase your fibre intake. Fibre will help lower your cholesterol and help protect against atherosclerosis. Drink about two litres of water each day. Reduce salt. 9 Dementia
Lifestyle choices For some time dementia was thought to be one of the few disease states where smoking might offer some protection. More recent studies have indicated, however, that smoking is associated with a higher risk of developing dementia. Smoking kills, and there is no reason to start or continue smoking. Occupational exposure to strong electromagnetic radiation is also associated with a higher risk of developing dementia. You may become exposed to electromagnetic radiation when using electrical tools such as sewing machines, electric typewriters, electric saws, and so on. To reduce your exposure, try to use only tools with electric motors that have been shielded. On current evidence, it appears that aluminium may not be a major factor in the later development of Alzheimer s disease after all. This conclusion is not definitive however, as some studies have suggested a link and we do know that aluminium is toxic to the nervous system. The best approach for you and your family is to limit your exposure to aluminium as much as you can. Water, antacids and deodorants can contain aluminium that is easily absorbed by your body. Vascular disease may be a major cause for both Alzheimer s and Vascular dementia, so controlling factors such as high blood pressure and atherosclerosis will also help prevent those dementias. Lifestyle measures you can implement to increase your vascular health include reducing salt in your diet, maintaining a healthy weight, increasing your physical fitness and not smoking. The pharmacological approach As there is currently no cure for dementia, the pharmacological approach to managing dementia is aimed at easing the symptoms rather than resolving the underlying causes. The primary pharmacological approach is to improve cognitive function (memory, orientation, attention and concentration). The main focus of recent times in this area has been on drugs called cholinesterase inhibitors, or anticholinesterase drugs, which preserve the amount of acetylcholine available within the brain. Acetylcholine is a major neurotransmitter that allows neurons in the brain to communicate with each other and therefore critical for proper memory and other cognitive functions. There are several classes of cholinesterase inhibitors. Donepezil (e.g. Aricept), Galantamine (e.g. Reminyl) and Memantine (e.g. Ebixa) have all been shown to improve cognitive function in people with Alzheimer s disease and Vascular dementia. All cholinesterase inhibitors have adverse effects, however, including anorexia, nausea, vomiting and diarrhoea. As the dementia will continue to progress, the effectiveness of these drugs will begin to wane after a while. Another pharmacological approach is to try to control the psychotic symptoms associated with dementia. Several classes of antipsychotic drugs have been demonstrated to have shortterm positive effects. Unfortunately, they also have high side-effect rates. Carbamazepine (e.g. Tegretol and Teril) seems to be the best tolerated. Antipsychotic medications are not suitable for treating Dementia with Lewy bodies. Antidepressants have only limited effect. As an inflammatory process may underpin Alzheimer s disease, non-steroidal antiinflammatory drugs (NSAIDs) have received some attention and may reduce the risk of 10 Dementia
developing dementia. However, the use of non-steroidal anti-inflammatory drugs has been linked to an increased risk of heart failure and stroke. The Complementary approach The approach taken by complementary or natural medicine therapists is also aimed at improving the availability of neurotransmitters such as acetylcholine. Herbs and nutritional supplements may also be used as antioxidants. Recent attention has focussed on improving or preserving the energy available within brain neurons so as to restore proper brain energetics and neuron function. Some popular herbs and supplements that may assist are listed below. Ginkgo biloba Ginkgo biloba (Ginkgo) has been used in China as a traditional medicine for more than 5000 years and is one of the top five prescribed medicines in Germany today. It has been widely studied to determine if it may improve memory in the elderly or dementia patients. A comprehensive review of this scientific literature found that, compared to a placebo, Ginkgo showed superior benefits after 12 weeks on cognition, mood and emotional problems, and in improving a person s ability to carry out their normal, everyday activities. Ginkgo has been shown to produce similar benefits as the Tacrine class of anticholinesterase drugs, and it is thought that Ginkgo should be just as effective as the more modern anticholinesterase drugs in treating mild to moderate dementia. Most of the research has been conducted on Ginkgo preparations containing 24 per cent flavone glycosides and six per cent terpene lactones. So if you decide to trial Ginkgo, check the label to make sure it meets those requirements. Note: Although Ginkgo is relatively safe, you should not take it if you are taking other bloodthinning medication such as Warfarin or a low dose Aspirin. It should also be discontinued several weeks before any surgery. When first taking Ginkgo, or any other product, take careful note of any possible side-effects; if necessary, stop taking Ginkgo and seek professional health care advice. Salvia officinalis Sage (Salvia officinalis) has been used for centuries to help memory and treat symptoms of dementia. Modern studies have now demonstrated that sage may improve cognitive functions of patients with mild to moderate Alzheimer s disease. It has also been shown to inhibit cholinesterase. Although quite safe in appropriate doses, sage must not be used by pregnant women or taken in excess. The essential oil should not be taken internally; when applied to the skin, the essential oil may cause irritation. Melissa officinalis Melissa officinalis is commonly known as Lemon Balm. Laboratory studies have shown that Lemon Balm inhibits cholinesterase. Clinical trials involving Lemon Balm have shown that it may also improve cognitive functions. Lemon Balm is accepted as being well tolerated, although it should be used with caution if you are taking other medications or have hypothyroidism. Coenzyme Q10 11 Dementia
Coenzyme Q10 (CoQ10) is one of the most important molecules your body s cells uses to make energy. CoQ10 has also been shown to prevent the breakdown of acetylcholine. This and other research is suggesting that CoQ10 may be useful in slowing the progress of Alzheimer s disease. However, as no human trials have been conducted, no firm conclusions can be made at present. Fish oils In addition to offering protection against the development of dementia, fish oils may also slow the progress of Alzheimer s disease. Fish oils are high in omega-3 fatty acids, including docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). A recent study showed that when fish oil capsules, formulated to contain 430mg DHA and 150mg EPA, were given to patients with mild to moderate Alzheimer s disease, the cognitive decline in those patients was significantly slowed. Aromatherapy The evidence regarding the efficacy of aromatherapy is not consistent. As there is some evidence that aromatherapy can help some patients become more relaxed, however, it may be worthwhile as part of an holistic care package. Oils often used are lavender, chamomile, bergamot, sandalwood and rose. They may be administered by oil burners, by adding to a warm bath, or during a massage. Be careful not to leave any vaporiser, especially those using candles, unsupervised in the presence of a patient with dementia. Australian Bush Flowers Essences Australian Bush Flowers are remedies that try to resolve disease by working on the mind, body and spirit to achieve emotional, spiritual and mental harmony. There are no studies to indicate if bush flowers may or may not be effective in managing dementia but they are generally regarded as safe to use and might be of assistance if you wish to try an additional or different approach. Potential bush flower remedies for dementia include: Emergency Essence: This remedy assists with the ability to cope. It is highly appropriate for any emotional upset, distress or panic. Isopogon: This flower essence helps with the ability to remember the past, and retrieve forgotten skills. Pink Mulla Mulla: Another remedy that helps with memory, especially memories of words. Massage Therapy Studies have shown that massage helps reduce anxiety in dementia patients, as well as agitated behaviour such as pacing, wandering and resisting. 12 Dementia
MANAGEMENT OF DEMENTIA Despite your best efforts, dementia may unfortunately still develop. If this happens you need to know how to best manage dementia s traumatic effects. This is beyond the scope of this article but places that can assist you in this are listed in the For More Help box. For More Help Alzheimer s Australia is a good place to start. This organisation operates Australia-wide and administers national dementia programs and services funded by the Commonwealth Government. Services include: The National Dementia Helpline (ph 1800 100 500) Face-to-face counselling A six- to eight-week program for people living with early stage dementia and their carers Help Sheets that provide information about dementia and living and caring for someone with dementia. These are available as free downloads Support groups for people who have been diagnosed with dementia and for carers. For more information, including the contact number for your state branch of Alzheimer s Australia, visit www.alzheimers.org.au. Matthew Boylan is a herbalist and nutritionist practising at Leichhardt in Sydney. He has a special interest in the chronic conditions of ageing. T: 02 9560 8450 13 Dementia