Chan KM

Forgetfulness:  It’s Not Always What You Think

 

Introduction

 

Many people regardless of age worry about becoming more forgetful. Whenever I spoke in a forum about forgetfulness and dementia, many in the audience would say they have all the symptoms I described.  They think forgetfulness IS dementia. In the past, memory loss and confusion were considered a normal part of aging. However, scientists now know that most people remain both alert and able as they age, although it may take them longer to remember things.

 

The interest in memory and dementia has lead to an increased numbers of ‘Memory Clinics’ to spring up in most Hospitals.  There has also been much progress in the understanding of this aspect of cognition, and different names have come up to describe the different stages in the continuum between normal cognition to the stage of obvious dementia:

Age associated memory impairment (AAMI):

 

In AAMI, the person is usually 50 years or older with subjective memory decline (i.e. person often realizes that his memory is declining) and objective evidence of memory loss (with memory test, and score of at least 1 SD below mean of younger patients).  However, there is adequate intellectual function and absence of dementia or memory affecting diseases e.g. stroke, cancer or poorly controlled diabetes.  By definition, AAMI does not interfere with Activities of Daily Living.  Incidence of dementia among patients with AAMI is about 2.5% per year.

 

Mild cognitive impairment (MCI):

 

In MCI, the cognitive changes are serious enough to be noticed by the individual or people around them, but not severe enough to interfere with daily life or independent function.  The disabilities they have also do not meet the diagnostic criteria for dementia.  MCI is classified based on the cognitive skills that are affected.  MCI that primarily affects memory is known as “amnestic MCI.” With amnestic MCI, a person may start to forget important information that he or she would previously have recalled easily, such as appointments, conversations or recent events.

MCI that affects thinking skills other than memory is known as “nonamnestic MCI.” Thinking skills that may be affected by nonamnestic MCI include the ability to make sound decisions, judge the time or sequence of steps needed to complete a complex task, or visual perception.

 

Some MCI remains stable for years; some may improve while some will progress to dementia.  Some studies have suggested an annual conversion rate from MCI to dementia as 3.3 – 4.2%.

 

Dementia:

 

People who have serious changes in their memory, personality, and behavior may suffer from a form of brain disease called dementia. The term dementia describes a group of symptoms that are caused by changes in brain function. Dementia symptoms may include poor recent memory; asking the same questions repeatedly; getting disoriented about time, people, and places; becoming lost in familiar places; being unable to follow directions or instructions; and neglecting personal safety, hygiene and nutrition. People with dementia lose their abilities at different rates.

 

There are many cognitive tests that can be administered to assess functions of various parts of the brain.  Most of these tests assess short-term memory (either as a 4 digit number, 3 or 5 unrelated objects to remember and recall later), orientation to time, person and place, language, ability to follow instructions and or abstract thinking skills.  The commonly used ones are the Mini Mental State Examination (MMSE), Chinese Mini Mental State Examination (CMMSE), Elderly Cognitive Assessment Questionnaire (ECAQ), Abbreviated Mental Test (AMT), Montreal Cognitive Assessment (MoCA) and the Clock Drawing Test (CDT) or Clock Completion Tests (CCT).  Scores that are below the ‘cut-off’ for that test indicates cognitive impairment.  The various components tested in the above tests will enable us to decide if they fit into the diagnostic criteria for dementia, as dementia is a common cause of cognitive impairment in older people.  In cases which are inconclusive after using these ‘bedside’ tests or when they are being assessed for decision making capacity, neuropsychological tests may be necessary.

 

The most commonly used criteria to diagnose dementia is the DSM IV criteria.

 

DSM IV criteria:

 

1. The development of multiple cognitive deficits manifested by both

 

(1) Memory impairment (impaired ability to learn new information or to recall previously learned information)

 

(2) One (or more) of the following cognitive disturbances:

 

(a)  Aphasia (language disturbance)

(b) Apraxia (impaired ability to carry out motor activities despite intact motor function)

(c)  Agnosia (failure to recognize or identify objects despite intact sensory function)

(d) Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)

 

1. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

 

1. The course is characterized by gradual onset and continuing cognitive decline.

 

1. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:

 

(1) Other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson’s disease, Huntington’s disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)

(2) Systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)

(3) Substance-induced conditions

 

1. The deficits do not occur exclusively during the course of a delirium.

 

1. The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Episode, Schizophrenia).

 

There are many causes of dementia, namely, Alzheimer’s disease (AD), Vascular Dementia (VaD), Dementia with Levy Body (DLB), Frontotemporal Dementia (FTD), Dementia associated with Parkinson’s Disease etc.

 

The two most common forms of dementia in older people are Alzheimer’s disease and vascular dementia. These types of dementia are irreversible, which means they cannot be cured. In Alzheimer’s disease, nerve cell changes in certain parts of the brain result in the death of a large number of cells. Symptoms of Alzheimer’s disease begin slowly and become steadily worse. As the disease progresses, symptoms range from mild forgetfulness to serious impairments in thinking, judgment, and the ability to perform daily activities. Eventually, patients may need total care.

 

In vascular dementia, a series of small strokes or changes in the brain’s blood supply may result in the death of brain tissue. The location in the brain where the small strokes occur determines the seriousness of the problem and the symptoms that arise. Symptoms that begin suddenly may be a sign of this kind of dementia. People with vascular dementia are likely to show signs of improvement or remain stable for long periods of time, then quickly develop new symptoms if more strokes occur. Vascular dementia due to multiple small strokes is also called ‘multi-infarct dementia’.  People can also develop vascular dementia without strokes, but through cerebral small vessel disease.  Cerebral small vessel disease is usually caused by hypertension, diabetes, hyperlipidemia and old age.  Both multi-infarcts and small vessel disease may co-exist together as causes of the dementia.

 

Similarly, both Alzheimer’s disease and vascular dementia may also co-exist together, and is often referred to as ‘Mixed Dementia.’

 

There are some conditions that may cause dementia-like symptoms, but may be reversible. Reversible conditions can be caused by infections, dehydration, vitamin deficiency and poor nutrition, abnormal electrolytes, hyper or hypoglycemia, side effects of medicines, problems with the thyroid gland or head injury.

 

Sometimes older people have emotional problems that can be mistaken for dementia. Feeling sad, lonely, worried, or bored may be more common for older people facing retirement or coping with the death of a spouse, relative, or friend. Adapting to these changes leaves some people feeling confused or forgetful.  Some older people who became depressed from whatever reasons may present with dementia-like symptoms but are not demented, hence, the term ‘Pseudo-Dementia’.

 

Medical conditions like these can be serious and should be treated by a doctor as soon as possible.  Therefore, when faced with a person who presents with dementia-like symptoms, the first step is to exclude reversible or treatable conditions.

 

Blood tests that may be done to exclude reversible or treatable causes include full blood counts, urea and electrolytes, thyroid function tests, liver function tests, glucose, calcium, Vit B12 and folic acid.  A brain scan (either CT or MRI) would be needed to make a diagnosis of vascular dementia.

 

Treatment

 

Even if the doctor diagnoses an irreversible form of dementia, much still can be done to treat the patient and help the family cope. A person with dementia should be under a doctor’s care, and may see a neurologist, psychiatrist, family doctor, internist, or geriatrician. The doctor can treat the patient’s physical and behavioral problems and answer the many questions that the person or family may have.

 

At present, there are only 2 main classes of medications that could improve cognition and reduce the rate of cognitive decline in Alzheimer’s disease. The first are the acetylcholine esterase inhibitors or AchEI, while the second are the N-methyl D aspartate antagonist or NMDA antagonist.  Examples of AchEI are donepezil, rivastigmine and galantamine, while the only NMDA antagonist is memantine.  Both classes of medication can be used to treat the whole range of dementia, from mild to severe dementia.  They can also be used in combination between the 2 classes but not within the same class (i.e. using 2 different AchEIs).  Both classes of medication can also be used for mild to moderate vascular dementia.

 

In vascular dementia, patients should prevent further strokes by controlling high blood pressure, monitoring and treating high blood cholesterol and diabetes, stop smoking and reduce weight. They should also be taking antiplatelet agents to prevent strokes and anticoagulants for those with atrial fibrillation.

 

Many people with dementia need no medication for behavioral problems. But for some people, doctors may prescribe medications to reduce agitation, anxiety, depression, or sleeping problems. These troublesome behaviors are common in people with dementia. Careful use of doctor-prescribed drugs may make some people with dementia more comfortable and make caring for them easier.

 

Family members and friends can assist people with dementia in continuing their daily routines, physical activities, and social contacts. People with dementia should be kept up to date about the details of their lives, such as the time of day, where they live, and what is happening at home or in the world. Memory aids may help in the day-to-day living of patients in the earlier stages of dementia. Some families find that a big calendar, a list of daily plans, notes about simple safety measures, and written directions describing how to use common household items are very useful aids. Establishing a fixed daily routine will help alleviate the anxiety of not knowing what to expect next and give them a sense of control.

 

General Health Tips for Seniors:

• Treat your brain like your muscles. You either use it or lose it. (lead on to discuss about memory / dementia)
• Proper nutrition is the foundation for all the systems in your body. If you don’t know where to start to get healthy, start with proper nutrition first. (lead to nutrition and diet for the elderly)
• Exercise does not merely make you look good. It also improve your mental health and prepares you to age gracefully. (exercise in the elderly and graceful ageing)
• Start having a hobby and develop interests and friendships outside of work so that when you retires, you are still kept occupied mentally and physically. (psychosocial aspects of ageing)
• Treat your existing medical illness properly. Untreated or uncontrolled illness is the surest way to poor health. (knows what illness you have and treat them adequately first).
• Sleeping is not a waste of time or youth. It is needed by the body to repair itself and to recover from the day’s physical and mental activities. Have at least 5 to 8 hours of sleep every night will keep your body and mind functioning well.
• Concentrate on building your bones when you are young. For when you are old, osteoporosis is the silent thief of bones.
• Just like a heart attack is an emergency to the cardiologist or a stroke is an emergency to the neurologist, a fall is an emergency to the geriatrician. You will never know when the next fall is going to change your life forever.
• Don’t ignore painful joints. Arthritis is common in old age, but can be managed and improve your quality of life.
• If you value your life, don’t smoke. If you value the life of those around you, don’t smoke. Stop smoking and give your lungs a new breath of life.

GERIATRIC CARE FOR CHRONIC DISEASES

 

Introduction:

 

Over the years, the pattern of diseases changes from acute to chronic.  While in the past, patients often die from acute conditions, like acute myocardial infarction, now, it is not uncommon to find many survivors, perhaps, not of just one AMI, but a number, and in the process, developed chronic or even intractable heart failure.  The same goes for strokes and fractures.

 

With improved and safer living environment, better nutrition and medical healthcare available, the average life expectancy of the Singapore population has risen to 78 years old in males and 82 years old in women.  This increase in life expectancy also meant that whatever medical conditions that they had developed at a younger age would accumulate and carry over into old age.  Not only that, these conditions would also manifest changes associated with end organ damage as a result of years of having that condition.  For example, a person may have high blood pressure from age of 50, and by 65 years old, he would have had high blood pressure for 15 years, and may start developing end organ damage like strokes, peripheral vascular disease, heart disease and or kidney damage.  As he grows older, he may develop certain conditions that are more prone in the elderly, like diabetes (affecting eyesight, sensation and nerves), Parkinson’s disease (affecting balance and movement), enlargement of prostate (affecting urination), arthritis (pain, instability and weakness) and so forth.

 

At the same time, bodily and organ changes occurs due to ageing.  Atrophy of organs and tissues occurs and their functional and reserve capacity declines.  They become even more prone to further insults from trauma, infection, inflammation, toxins, chemicals and drugs.

 

All these meant that the older person is prone to have medical conditions and their complications affecting many organs.  Sorting out which is caused by disease, which is caused by ageing, which is acute, which is chronic or acute on chronic, becomes more complicated.  Many chronic conditions have no cure.  In the light of an elderly person with multiple and chronic medical problems intertwined with ageing issues and poor reserves, geriatric care becomes the mainstay of management.

 

The traditional model of medical care takes the ‘organ specific’ route.  In other words, a heart condition is managed by a cardiologist, lung condition by a respiratory physician, strokes by neurologist, dementia by psychiatrist and so on.  But from the above scenario, it would be translated to having multiple specialists managing a single elderly person with chronic diseases.  Multiple specialists, however, does not necessarily translate to better care as each look only towards their own area of specialty and this often lead to multiple doctors’ appointments and polypharmacy.  There is also no single doctor to take charge of coordinating care and medications, and this role may sometimes fall onto a caregiver who is likely to be a layperson, and sometimes, even the maid.

 

The elderly person also does not manifest illness in the same way as the younger population.  Neuropathy may mask the pain of a septic or gouty arthritis while dementia may cause them to forget that they had a recent fall or trauma, or some symptoms which may be useful to aid in their diagnosis.  A change in environment, such as hospitalization, could cause acute confusion in an elderly person with borderline dementia.  A chest infection, even before the first signs of cough, phlegm or fever, may manifest as a fall or incontinence.  Thus, illnesses may present as vague or totally unrelated symptoms which are peculiar yet common in the elderly:  like instability, immobility, incontinence and impaired cognition, also referred to as the Giants of Geriatric Medicine.  As in all medicine, the key to treatment is early detection.  Such vague presentations may make diagnosis difficult.  Late diagnosis lead to higher morbidity, a longer hospital stay, higher medical cost, poorer outcome and higher mortality.

 

Yet, with early diagnosis and appropriate treatment, outcomes in the elderly remained good, even in ICU cases.  In studies of patients admitted to the ICU, when severity of illness is controlled, differences in survival between age groups disappear.  Preadmission health status, functional status, and physiologic states were more important predictors of long-term survival after intensive care than age was.

 

Response to treatment by the elderly is also different from the young.  The difference in response stem from age related immune responses, changes in pharmacokinetics and pharmacodynamics.  Thus, it led Ignatz Nascher to propose that disease and medical care of the aged should be recognised as a separate specialty and invented the term “geriatrics” in 1909.   However, the growth of geriatric medicine and healthcare of the elderly is often attributed to the pioneering work of Majorie Warren who successfully treated and rehabilitated seemingly hopeless elderly patients in the UK in the 1930s.  Today, the British Geriatric Society defines Geriatric Care as that branch of general medicine concerned with the clinical, preventive, remedial and social aspects of illness in older people” and the goal of geriatric care is “to restore an ill and disabled person to a level of maximum ability and wherever possible return the person to an independent life at home.”  The wide definition necessarily implies that geriatric care must be delivered in both hospitals and community, requires a multidisciplinary approach and shares overlapping philosophies with preventive, rehabilitation, palliative and family medicine.

 

Principles of geriatric care

 

The cornerstone of geriatric care is a comprehensive geriatric assessment (CGA), where any elderly presenting to the doctor should have an opportunistic assessment – not just of the complaints which brought them, but also to ‘hidden’ conditions like incontinence, depression, dementia, osteoporosis and falls.  These ‘hidden’ problems are commonly found in chronic diseases like stroke and arthritis.  CGA is likely to identify conditions which could be treated early or potential problem areas which should be monitored closely.

 

The second cornerstone of geriatric care is an obsession with functional abilities (or disabilities) of the elderly person.  This obsession with function arose from the concept of ‘ageing in place’.  ‘Ageing in place’ is the concept of allowing the older person to grow old gracefully at their own home without going into a nursing home for example.  This is possible only when they have the necessary functions to do so.  Chronic diseases in the elderly very often lead to frailty of the person, and the hallmarks of frailty include weight loss, sarcopenia (loss of muscle mass), muscle weakness and instability.  Therefore, the need for geriatric rehabilitation is something that we are constantly on a look out for.  In some patients, there is only so much we can do for them.  To further optimize their independence, we need to look at the environment to make it more elderly friendly.  Hence, home modifications and use of equipment and technology may just be needed to allow the elderly person to remain at home.

 

The third cornerstone of geriatric care is the multidisciplinary team.  Because of the diverse nature of chronic diseases, certain aspects of care may require further attention.  The ‘usual’ multidisciplinary team would include the geriatrician as team leader, a (preferably) gerontological trained nurse, a physiotherapist, an occupational therapist, a speech therapist and a social worker.  Adhoc members of the team may include a dietitian (when nutrition is an issue), a psycho-geriatrician (or geriatric psychiatrist, when there are behavioural problems that needed attention), a pharmacist (to review the polypharmacy and reduce risk of drug interactions) and even an orthopaedic surgeon (when there are complicated bones and joints issues).

 

One major role of the multidisciplinary team is to manage the discharge of the elderly person.  This is called discharge planning.  This is probably the fourth cornerstone of geriatric care.  It is very important if we do not want to see the ‘revolving door syndrome’ – where because of inadequate planning, the elderly person was discharged from hospital in a suboptimal state (whether medical, physical, emotional, social or home environment) and ended up readmitted soon after the discharge.  It is not uncommon to find older patients getting in and out of hospital, like in a revolving door.

 

The fifth cornerstone of geriatric care is the appropriate use of community resources to assist the elderly.  Sometimes, it may be necessary to discharge the elderly to a transitional care facility between hospital and the home.  In Singapore, we have community hospitals which serve this function.  The purposes of such a facility are many folds:  1. to allow the elderly patient more time for rehabilitation so that they can be more functional at home since the acute care hospital is usually in a hurry to discharge them because of bed shortages.  2.  to train the caregiver (be it the maid or a member of the family) to provide adequate and competent care, 3.  to just simply wait for the arrival of a caregiver or  4.  to provide respite care to the caregivers.  Respite care for the caregivers has been recognized to have an important role in ensuring continual care, better quality of care, reduction in caregiver stress and reduction in elder abuse.  In this respect, caregiver support is also a part of the total package of geriatric care.  Once the elderly person is discharged home, the appropriate use of social day centres, day care centres, dementia day centres, day rehabilitation centres, befriender services, meals services and patient escort services can lighten the load of care for them at home.

 

Geriatric care should also be provided where the elderly are because of their lack of mobility.  Hence, it includes home care services which comprises of home medical, home nursing and home therapy services.  Various studies have found that a targeted home-based program consisting of 6 months of physical therapy reduces the progression of functional decline, especially in the physically frail and elderly.

 

Conclusion

 

The ageing population is not unique to Singapore.  It is a worldwide phenomenon.  Doctors will have to be familiar with managing the elderly regardless of what discipline they are practicing, especially those dealing with chronic diseases.  It is also not feasible to just depend on geriatricians to handle the sick elderly.  Treating the sick elderly in the same manner like that of a younger sick person will have disastrous results.

 

Many laypersons and some healthcare workers confuse geriatric care with prolonging life.  Geriatric care focuses on holistic and appropriate care to the older person with the aim to achieve better quality of life for the person, and has nothing to do with the mere prolongation of life ‘at all cost.’  Part of geriatric care may involve the discussion of ‘do not resuscitate’ orders with the family and caregivers.

Medicine and the Elderly

It is sometimes evitable for the elderly to be taking medicine.  There are some gender differences in the way elderly takes medicine.  Elderly men tend to be more stoic and tend not to see a doctor until they are quite sick, and once they are well, they also have a tendency to default their follow up.  Women, on the other hand, tend to seek consultation earlier and they tend to be more ‘obedient’ in following the orders of the doctor with respect to taking their medications.  Hence, I am not surprised that your dad is one of those who ‘always disobey doctor’s prescribed medications’.

However, I feel that the key to getting those who are not so compliant into taking their medications is patient education.  Half-truths are as damaging as ignorance, or may be even worst.  People have the tendency to think that traditional Chinese medicine (TCM) is not medicine.  In fact, medicines are basically chemical agents that are meant to improve the person’s health, either by enhancing the health or treating the disease.  Western medicine are man-made or man-modified chemical agents, while some TCM are naturally occurring chemical agents.  Both can be beneficial to the person if taken for the correct indications and at the correct dose, and both can be equally damaging if abused.

Similarly, all these chemical agents are absorbed in the gut and all will pass through the liver, detoxified and excreted either through the liver (via bile) or through the kidneys (via urine).  So, both also have the potential to damage the liver and the kidney if taken at the wrong dose or for the wrong indications.  In Western medicine, through various studies, we actually know that certain combinations of medicine are beneficial for the person; for example, the use of ACE inhibitors in a diabetic patient with high blood pressure can protect their kidneys from damage due to their diabetes.  I am sure it is the same for TCM where they have their own system of combining herbs for the treatment and protection of the body.  The point is, therefore, that they should obtain their TCM from a suitably qualified TCM Practitioner, just as they would get their Western medicine from a suitably qualified doctor.  Since we do not know exactly the chemical content of naturally occurring herbs, it is always prudent not to take it with Western medicine.  But knowing our local elderly, you know that some of them will do so regardless of what you tell them.  Therefore, if they must, take their TCM at least 2 hours apart from their Western medicine.  TCM should not be taken at all if the person is taking certain Western medicine – example, oral anticoagulants like Warfarin.  This is because depending on the type of TCM, they could either enhance the effect of Warfarin and cause bleeding, or reduce the effect of Warfarin and render it ineffective as a blood thinner.

Other ways of ensuring compliance of taking medicine include simplifying the regime.  Some regimes are so complicated that it is confusing to the elderly.  For example, a certain medicine to be taken before food once a day except two days of the week that it is taken twice a day.  Using a pill box to organize the pills helps.  The elderly also should have an understanding of what they are taking, rather than just swallow a whole lot of medicine without knowing what they are for.

If you detect a genuine difficulty in compliance to medicine because the person just cannot remember in spite of all the above aids given, it could be that the person is suffering from dementia and this warrants an assessment.

When a person takes a medicine and develops a rash or hives which are widespread and itchy, then this person may be allergic to the medicine taken.  He has a drug allergy and not skin allergy.  Sometimes, the offending agent may not be so obvious.  It may be some air borne dust, insect bite, food or even heat, friction, sunlight and exercise.  The skin reacts to these stimuli by releasing certain chemicals that cause swelling, itch, redness and warmth.  In the elderly, a common cause of itchy skin is actually xeroderma or dry skin.

The different types of skin allergy are eczema, allergic contact dermatitis, urticaria and angioedema.  Skin allergy may be a symptom of other medical conditions like asthma, skin infections and blood disorders.

If skin allergy is left untreated, the patient may have a poor quality of life because of the itch, which varies in intensity.  Their sleep may be disturbed.  The scratching will damage the skin and increases the risk of skin infection.  The underlying medical condition like asthma and blood disorder may not be discovered.