The 7th century B.C., Greek physician Pythagoras is credited as being the first person to document the mental decline that can occur with advanced age. Describing the later stages of life he wrote, “The scene of mortal existence closes, after a length of time, to which, very fortunately, few of the humans species arrives. The system returns to the imbecility of the first epoch of the infancy.”
In 1684 the English anatomist and physician Thomas Willis identified a set of causes for dementia that included head injury, stroke, alcohol and drug abuse, disease and epilepsy. Prior to this, dementia was considered a normal consequence of aging. In 1776 the Scottish physician William Cullen further developed the concept of dementia by including it in his classification of diseases as a Neurosis (nervous disease). This was the first time that dementia, defined by Cullen as a “decay of perception and memory in old age” was recognized as a medical diagnosis.
Perhaps the most significant advance in the understanding of dementia occurred in 1906 when German physician Aloysius Alzheimer, published a case study of Auguste Deter, a 56 year old patient who showed profound memory loss, unfounded suspicion and paranoia toward her family, as well as significant psychological decline. In her brain at autopsy, he saw dramatic shrinkage and abnormal deposits in and around nerve cells. Alzheimer called Deter’s condition the “disease of forgetfulness.” Emil Kraepelin, a German psychiatrist who worked with Dr. Alzheimer, later named this condition “Alzheimer’s Disease” in the 8th edition of his book Psychiatrie.
Dementia, also called major neurocognitive disorder, is a general term used for a decline in cognitive functioning severe enough to interfere with daily life. Dementia is not a disease itself; instead, it is a group of symptoms caused by other conditions that have damaged an individual’s brain. Symptoms that signal the onset of dementia are usually subtle and may not be noticeable for a number of years. The characteristic symptoms of dementia include memory loss, communication difficulties, confusion, changes in mood and apathy.
Memory loss in dementia is often subtle and tends to involve short-term memories. The individual may be able to remember years past, but not what they had for breakfast. Signs of memory loss may include forgetting where they left something, struggling to remember why they went into a particular room, or forgetting what they were supposed to do on any given day.
Communication difficulties make it hard for individuals with dementia to carry on normal conversations. They may struggle with vocabulary, have problems finding the right word or call things by the wrong name. To try and overcome this problem, they may talk around a word they cannot remember (circumlocution) or substitute an inappropriate word, making their statements, at times, almost incomprehensible.
Confusion usually first appears as problems with more complex tasks such as balancing the checkbook or playing games that have a lot of rules. Learning how to do new things or following new routines becomes more and more difficult. As the cognitive decline progresses they may struggle to complete familiar tasks. Sometimes they may even forget where they are or how they got there.
Changes in mood are common in dementia. Individuals can become suspicious, depressed, fearful and anxious. They may show increased irritability and explosive outbursts of anger when their routine or schedule is disrupted. Sudden mood swings can occur regularly. For example, it is not uncommon for individuals with dementia to become friendly and affectionate within a few minutes of an angry outburst.
Apathy is frequently a problem in individuals with dementia. In the early stages, they begin to lose interest in hobbies or activities they once considered pleasurable. They may not want to go out anymore or to do anything fun. Emotionally they may appear flat and have no interest in spending time with friends or family.
Types of Dementia
For a person to be diagnosed with dementia (major neurocognitive disorder), he or she must show a significant cognitive decline in one or more of the following areas: attention, executive function, learning and memory, language, perceptual motor, and social cognition. In addition, the individual’s capacity for independence in everyday activities must be impaired. The following are some of the most common types of dementia and their causes.
Alzheimer’s Disease (AD) is the most common cause of dementia, accounting for 60-80% of all cases. In AD a protein called tau becomes twisted inside the brain’s cells (neurons) forming abnormal bundles, called neurofibrillary tangles. Plaques, abnormal clumps of the amyloid protein, also appear in high concentration in the spaces between the brain cells in AD patients. These two protein accumulations cause the neurons to stop functioning properly and die.
Vascular Disease is the second most common cause of dementia accounting for about 10% of all cases. In this type of dementia, damage to the vessels supplying blood to the brain deprives neurons of the nutrients and oxygen they need to function normally. Vascular dementia can result from a number of conditions that narrow or damage the brain’s blood vessels; these include stroke, diabetes and hypertension. The associated features of vascular disease will be discussed in the next chapter.
Lewy Body Disease
Lewy Body Disease (LBD) is one of the most common causes of dementia, after Alzheimer’s disease and vascular disease. In this type of dementia, a protein called alpha-synuclein accumulates inside neurons forming balloon-like structures called Lewy bodies. In LBD, cells in a region deep in the brain called the substantia nigra die or become impaired, and the brain’s outer layer (cortex) degenerates.
Frontotemporal Dementia (FTD) is not a single disease but rather a group of brain disorders that accounts for up to 10% of all dementia cases. The common characteristic of the diseases that cause this type of dementia is atrophy or shrinking in the frontal and temporal lobes of the brain. Types of FTD include behavioral variant FTD, primary progressive aphasia, FTD with parkinsonism linked to chromosome 17 and Pick’s disease.
Mixed Dementia results from more than one medical condition. The most common form of mixed dementia is caused by both Alzheimer’s and vascular disease.
Prevalence and Age of Onset
The prevalence of dementia (any type) in the United States among individuals 71 or older is approximately 13.9%. The prevalence rate rises steeply with age, from 5% of those 71-79 years to 37.4% of those 90 years and older. Men and women are equally affected by dementia. Of the neurodegenerative dementias, Lewy body disease and frontotemporal dementia have the earliest average onset while Alzheimer’s disease has the latest. Vascular dementia can occur at any age but the prevalence increases dramatically after age 65.
Treatment & Support
While there is presently no cure for the diseases that cause the neurodegenerative dementias, a number of treatments and interventions have been shown to slow or minimize the development of symptoms.
Medications that boost the levels of ACh in the brain called cholinesterase inhibitors are the first line of treatment for Alzheimer’s and Lewy Body Disease. This class of medications includes Aricept (donepezil), Exelon (rivastigmine) and Razadyne (galantamine). Namenda (memantine), a drug that raises the levels of the neurotransmitter glutamate in the brain has also been shown to be effective in minimizing the symptoms of dementia. Research has shown that combining Namenda and a cholinesterase inhibitor together often results in an even greater beneficial effect.
It is fairly common for people with dementia to also have depression; antidepressants are often prescribed to deal with mood issues in these patients. In addition, antipsychotics may be used to treat individuals with dementia who show disruptive behaviors (e.g., aggression).
Cognitive Stimulation Therapy
A non-invasive, psychological intervention for those with a cognitive impairment, cognitive stimulation therapy (CST) focuses on the improvement and strengthening of spared cognitive functions and resources as well as on the maintenance of social and interaction skills, with the goal of improving mood and quality of life. CST involves taking part in activities and exercises designed to improve memory, problem-solving skills and language ability.
Individuals with an incurable illness such as dementia may be offered palliative care so they are able to live as well as possible until their death. The goal of palliative care is not to cure the disease but rather, to improve the individual’s quality of life-not just in body but also in mind and spirit. Palliative care is as much about supporting the caregiver or family as it is about treating the patient suffering with dementia.
A Spiritual Perspective
With an average life expectancy of 78.8 years (81.2 years for women, 76.4 years for men) in the United States today, it is common to encounter the elderly in daily life. This was not the case in ancient times. Based on age reports in the biblical text, the average life expectancy of kings in biblical times was only in the mid-forties. In comparison, the common peasant male had to survive under harsher conditions than those enjoyed by royalty and had a life expectancy of less than 30 years. Life expectancy was even shorter for peasant women of the time who, in addition to living with poverty, disease and violence, had to survive multiple pregnancies and deliveries.
Despite the short life expectancy of biblical times, old age is a common theme throughout the scriptures. Advanced age was considered a blessing of God (Exodus 23:26; Proverbs 10:27; 16:31), wisdom was attributed to the aged (Deuteronomy 32:7; 1 Kings 12:6; Job 12:12; 32:7), and the young were called to honor, respect, and care for the elderly (Exodus 20:12; Leviticus 19:32; 1 Timothy 5:1-4). While the biblical writers correctly recognized old age as a period of physical deterioration (Genesis 18:11; 1 Kings 1:1; Psalm 71:9; 102:26; Ecclesiastes 4:9), only a few references are made to the mental decline that can occur with advanced age (Job 12:20).
The scriptures are clear, those advanced in age are to be honored and cared for by the church. Their presence within the fellowship is both a reminder of our faith heritage as well as the opportunity for the wisdom of experience to be passed onto the next generation. In the face of dementia the elderly are to be cared for, and protected from those that might take advantage of them.
The links and information below will provide you with a starting point in terms of finding mental health care providers, treatment facilities and support groups for those struggling with dementia.
Mental Health Care Providers
When assisting an individual it is important to help them to find the right type of mental health care provider. Theses links will assist you in beginning your provider search, but knowing and building relationships with providers in your area can prove invaluable. Both in aiding the individual in getting an appointment and being able to better support them as they begin receiving professional treatment.
An individual struggling with dementia will most likely need to see a neurologist or a psychiatrist.
By providing your zip code the following search engines will give you information about local mental health care providers.
In some people, dementia can become so severe that a hospital stay or elder care facility is needed. This may be necessary if the individuals seeking your care can’t take care of themselves properly.
By providing your zip code the following search engine will give you information about hospitals and elder facilities in your area.
By providing your zip code the following search engine will give you information about mental health treatment facilities in your area.
Supporting the Family
Many times the family caring for an individual with a dementia is overlooked. They are often the front line support for the individual. The responsibility of care can take a physical and psychological toll on caregivers, who are many times in as much need of support as the individual that has the illness. Caregiver support groups are available for the families of those struggling with dementia.
These links will give you information on caregiver (family) support groups in your area.
Alzheimer’s Association of America Alzheimer’s Foundation of AmericaNational Association for the Mentally Ill – Family Support Group National Association for the Mentally Ill – Family to Family Support GroupGrace Alliance
Here are some links to aid you in learning more about dementia. The more information you have, the better you will be able to help those seeking your guidance.
First Step – What to do once a diagnosis has been made.
Daily Steps – Developing a holistic mental health care plan.
Difficult Steps – Navigating destructive behavior and legal issues.