Good morning cherished readers, I trust you are all doing well? Well I am. This post aims to give you an overview of dementia, as well as guide you through how to identify dementia, a neurocognitive disorder from a history taken. As usual I will like to start with a story from the archives.
During my second week in my Psychiatry rotation, a 74 year old man was referred on account of irrelevant talk from the Family Medicine department. But then irrelevant talk was not a diagnosis, it was my duty to take further history to identify the cause of this irrelevant speech in this elderly man; hence my presence in my current location: Consulting room 3. This man was seen with his middle aged daughter to give further history about her father’s illness.
The additional complaints I further gathered were forgetfulness of a year’s duration and poor sleep of 2 months duration, associated with the history of irrelevant talk of 2 months duration. But then who defines irrelevant talk? The psychiatrist or the patient’s relative? Basically when you are talking out of context to the topic being discussed with both intentions of either doing that or not, you are exhibiting irrelevant talk. For most of the patients, this is not a deliberate act; this is something they cannot control. They just spew spurious information from their guts as time and the topic progresses that gestures attempted at them to stop talking proves futile. They then enter the phase of excessive talk.
Back to the story, this man had no chronic illness and was apparently well until about a year ago, he was noticed to have become easily forgetful. This was something his relatives pushed under the carpet until it got to the point he could not remember the names of places he found himself in his own house currently and gave his relatives weird formed names. The forgetfulness worsened until he could not also identify the names of locations he had been to outside his home. For this, the relatives sought no intervention until now, when matters had worsened because they attributed the symptoms to old age. But my late 90 year old grandfather could give details surrounding his purchase of his cocoa farm to how he met my grandmother to the names of each of his fourteen children in his current state. What then actually constitutes remembrance? A complex human brain is needed for this phenomenon. A complete nature of the mechanisms involved in attributing memory has to be understood.
To make matters worse, he kept asking the same questions repetitively throughout the day and misplaced things easily.
2 months before presentation, his daughters noticed he had begun sleeping poorly, because he had begun seeing imaginary people in his room during which he was seen engaging in different encounters from well-dressed battles to begging pleas for mercy. He also complained these imaginary beings had come to occupy his entire room; for which he had no place to sleep. There were even nights, he could see his wife in his room staring at him – for which he placed a torch on his head in response, when his wife was fast asleep in another room.
Also, he could not differentiate clean clothes from dirty clothes and was seen wearing dirty clothes to church because his vision had deteriorated. The forgetfulness worsened to the point, he even could not remember whether he had taken his bath or not.
His daughter visited his room in an attempt to tidy the room and realized he had confiscated different items spanning from her driver’s license to clothes of his wife; instances the patient had no memory of.
This alarmed her for which she presented to a nearby hospital and was referred to our clinic for further management after being put on dyslipidemic and antihypertensives when his blood pressure and cholesterol was found to be elevated.
Further history revealed there was associated fatuous laughter in response to these images. He denied hearing voices of any sort and he had disposed of an amount of 2000 cedis with no apparent reason one morning during his jogging sessions. There is also a positive history of mental illness in the late father and maternal aunt.
On presentation, he had a blood pressure of 140/80mmHg; probably because the antihypertensives were working and a Mental State Examination revealed an elderly man who looked his stated age in a blue suit with black trousers with marked circumstantiality in thought form, impaired judgement, attention and concentration. Other parameters were normal. A Mini Mental State Examination yielded a score of 22 for which he was diagnosed as having mild cognitive impairment.
An impression of Alzheimer’s Dementia was made predominantly from the history for which laboratory investigations were ordered including an MRI of the brain. He was subsequently put on medications and scheduled for a 2 weekly review with the results of the laboratory investigations and an MRI of his brain.
A review after 2 weeks with results of the MRI confirmed our diagnosis of Alzheimer’s disease with a normal liver function test, full blood count and blood cholesterol levels.
Dementia also referred to as a major neurocognitive disorder is marked by severe impairment in memory, judgement, orientation and cognition. Cognition defined by the Merriam Webster, relates to, or involves conscious intellectual activity such as thinking, reasoning and remembering. The syndrome of Dementia is caused by a wide range of diseases, but the majority of cases are due to Alzheimer’s disease which is the commonest cause, followed by vascular dementia and dementia of Lewy bodies. Only a small proportion of cases are currently potentially reversible.
Although dementia is a generalized disorder, it often begins with behavioural disturbances. However International Classification of Diseases 10 used in psychiatry requires impairment in two or more cognitive domains (memory, language, abstract thinking and judgement, praxis, personality and social conduct) sufficient to interfere with social or occupational functioning. Deficits may be too mild or circumscribed to fulfil this definition, and are then called mild cognitive impairment.
The presenting complaint in dementia is usually of poor memory. Other features include disturbances of behaviour, language, personality, mood, or perception. Perception is the ability to see, hear, or become aware of something through the sense organs.
The clinical picture is much determined by the patient’s premorbid personality as well as by the underlying cause. A premorbid personality is a character trait which was present prior to the cultivation of the mental illness or disorder. People with good social skills may continue to function adequately despite severe intellectual deterioration.
Dementia is often exposed by a change in social circumstances or an intercurrent illness. The elderly, socially isolated, or deaf are less likely to compensate for failing intellectual abilities however their difficulties may go unrecognized or be dismissed.
Forgetfulness is usually early and prominent, but may sometimes be difficult to detect in the early stages. Impaired attention and concentration are common and non-specific. Difficulty with new learning is usually the most conspicuous feature. Memory loss is more evident for recent than for more remote events. Disturbed episodic memory is manifested as forgetfulness for recent day to day events with relative preservation of general knowledge about the world at large.
As dementia worsens, patients are less able to care for themselves and they neglect social conventions with later disorientation to time, person and place. Behaviour becomes aimless, and stereotypies and mannerisms may appear. Mannerisms are normal actions carried out in a peculiar fashion, usually in an attempt to call for attention. A stereotypy is a repetitive or ritualistic movement, posture, or utterance. Stereotypies may be simple movements such as body rocking, or complex, such as self-caressing, crossing and uncrossing of legs, and marching in place.
Thinking then slows in dementia, and becomes impoverished in content. In the later stages, thinking becomes grossly fragmented and incoherent as reflected in the patient’s speech with syntactical and dysnomic errors. Eventually the patient may become mute. Mortality is increased, with death often following bronchopneumonia and a terminal coma.
Behavioural and psychotic features often accompany the cognitive deficits which may appear to be part of the underlying biology of the disease process. This may be a psychological response to the realization of cognitive decline. Mood disturbances are particularly common, together with distress, anxiety, irritability, and sometimes aggression. Later emotional responses become blunted, and sudden, apparently random, mood changes occur.
The balance of these core symptoms and signs, together with some additional features, forms the basis for the clinical differentiation between the various causes of dementia.
It is paramount you recognize these signs and symptoms of dementia and not spend long hours at prayer grounds because dementia is a gradual process for which its progression could be halted by your early visit to the hospital. See a psychiatrist who would help freeze the progress of this neurocognitive disorder by taking a history, performing a mini mental state examination and diagnosing the type of dementia; prescribing medications for it. Laboratory investigations may be conducted to find out the state of the organs destined to receive these medications.
Imaging of the brain may be conducted to reveal the specific type of dementia. Laboratory investigations may also reveal the cause of specific types of dementia such as vascular dementia for which blood lipid profile parameters may be markedly raised with associated hypertension, as diagnosed by the sphygmomanometer.
Be reassured that, in the hands of competent psychiatrists, your relative, and you suffering from dementia are in safe hands. Although the symptoms may not completely resolve, our aim is to aid the patient function in the social and occupational setting with minimal-to-no dependence on anyone.
Thanks for reading. Enjoy your Sunday.
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