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Dementia: Causes, risks and how to manage it

Health

Dementia: Causes, risks and how to manage it

By Diana Bauza

Dr. Charles Olaro, the Director Clinical Services, Ministry of Health

Dr. Charles Olaro, the Director Clinical Services, Ministry of Health

It is heartbreaking to see a loved one deteriorate as their memory fades from forgetfulness to oblivion. That is what happened to my sweet grandmother, God bless her soul!

She started with talking to herself; many times, shaking her head in denial. As we saw this, we came to a conclusion that it was the stress of being forced out of her home for road expansion that had caused this condition.

As family, we understood her pain and tried to comfort her but in vain. She could not come to terms with losing the one place she had created for herself after a brutal divorce. Her home was her lifetime achievement, an accomplishment that proved a woman could stand on her own without the help of a man. Even when my uncles promised to get her a suitable place, her thoughts were it could not amount to her home.

When she chose to go to her late mother’s village we were relieved. From our point of view, there were still friends and relatives she could relate with and these would comfort her. Unfortunately our relief was short lived. We later realized that even the village could not keep away from her the painful memories of losing her home.

She started to withdraw from others, keeping to her room in misery and anguish. It was from there that her forgetfulness started. She could be holding in her hand the same thing she was looking for. When she started losing her sense of direction that is when our relatives realized that her situation was serious and required medical attention.

She was taken to my aunt’s home in Kireka where she was put on medication to treat her depression. At that time her doctor assured us that her condition was nothing to cause much concern. If we showered her with love all would be well. We did that but it did not work.

Her condition continued to deteriorate. By the time she was taken to Mulago Hospital and diagnosed with dementia, it was too late. The doctor said there was nothing they could do to reverse her condition; it was just going to get worse.

Time came when she was only living in the past. One time she asked why she was living with her daughter yet she had a husband. She had completely forgotten that she had divorced that said husband a long time ago and he was someone she totally detested. Trying to convince her to stay was a very big problem.

With time, our faces started to disappear from her mind. She could not tell who we were. Sometimes she would scream for help that she had been kidnapped. The neighbourhood understood her condition so we were safe from suspicion of committing the crime. By the time she died she had turned into a baby, her memory totally gone. She could not recognise her surroundings or interact. She was 74 years, physically strong but mentally helpless.  This is an example of what people go through while they suffer from dementia.

What is Dementia?

The World Health Organization (WHO) describes dementia as a syndrome in which there is deterioration in memory, thinking, behaviour and the ability to perform everyday activities. As a syndrome, it is usually of a chronic or progressive nature in which there is deterioration in cognitive function.

Dr. Charles Olaro, the Director Clinical Services, Ministry of Health, explains cognitive function as the ability to process thought; the ability to recognize something for what it is for example a person being able to tell a man from a woman.

“A person may start behaving abnormally for example he or she may take off their clothes and start to urinate in the presence of an audience without a sense of modesty,” Dr. Olaro says.

Prevalence of dementia

Dementia is most likely to attack people in their old age

Dementia is most likely to attack people in their old age

While dementia mainly affects older people, according to the WHO, it is not a normal part of ageing. The WHO says that about 50 million people around the world live with dementia with an emergence of nearly 10 million new cases every year. The total number of people with dementia is projected to reach 82 million in 2030 and 152 in 2050. Much of this increase is attributable to the rising number of cases in low and middle-income countries.

The prevalence of Dementia in Uganda is not known. There has been no specific study to reveal how many people are affected, according to Dr. Olaro.

Types of dementia

There are many different types of dementia with Alzheimer’s disease being the most common. Others include vascular dementia, often related with vascular disease and injuries, dementia with Lewy, and a group of diseases that contribute to fronto-temporal dementia (degeneration of the frontal lobe of the brain).

Alzheimer’s disease

This accounts for an estimated 60 to 70 percent of dementia cases recorded across the world. Dr. Joseph Onyera of Central Medical Centre in Kyengera says Alzheimer’s disease is a variable shrinking of the brain. Due to its progressive nature, it slowly causes impairment in memory and cognitive function, with time causing the brain matter to reduce in size.

Alzheimer’s disease is mostly characterized with memory loss, word finding difficulties, poor reasoning, poor judgment, inattention, lack of insight, disorientation and behavior changes.

The problem with Alzheimer’s disease, as disclosed by the Alzheimer’s Association, the leading voluntary health organization in Alzheimer’s care, support and research, is that damage to the brain begins years before symptoms appear. By the time the symptoms appear, the brain is showing significant shrinkage with a high loss of brain cells and no hope for cure.

Vascular dementia

This type of dementia is less common as a sole cause of dementia than Alzheimer’s disease, accounting for about 10 percent of dementia cases.

It occurs from blood vessel blockage or damage leading to strokes or bleeding in the brain. It can be caused by an injury or a disease affecting blood supply to the brain.

“When someone suffers from an injury that cuts off blood supply to a part of a brain, that part of the brain will not function and its role will not be played. If that part deals with memory, memory loss will occur,” Dr. Onyera says.

The location, number and size of the brain injuries determine whether dementia will result and how the individual’s thinking and physical functioning will be affected, according to the Alzheimer’s Association.

Dementia with Lewy bodies (DLB)

Dementia with Lewy Bodies is characterized with primary symptoms of visual and auditory hallucinations, reduced motivation to perform tasks with other classical symptoms. When it comes to visual and auditory hallucinations, Onyera says someone may see something that no one else can see. An example is of people who claim to see ghosts and also claim to hear those ghosts commanding them to do certain things.

Frontotemporal dementia

Frontotemporal dementia includes dementias such as behavioral-variant Fronto temporal lobar degeneration (FTLD), primary progressive aphasia, Pick’s disease, corticobasal degeneration and progressive supranuclear palsy.

This type of dementia is characterized by drastic personality and behavior changes coupled with depression, isolation and anxiety and language difficulties. Nerve cells in the front and side regions of the brain are especially affected.

Mixed dementia

A person can suffer from more than one type of dementia at a go. Most commonly Alzheimer’s disease combined with vascular dementia, followed by Alzheimer’s disease with Dementia with Lewy bodies, and Alzheimer’s disease with vascular dementia and dementia with Lewy bodies. Vascular dementia with dementia with Lewy bodies is much less common.

Dr. Onyera says that the likelihood of having mixed dementia increases with age and is highest in the oldest-old (people aged 85 or older).

Symptoms of dementia

“It is always not the case that whenever someone has memory problems, he or she has dementia especially the Alzheimer’s disease,” says Dr. Olaro. “There are a number of causes of memory loss which are not related to dementia such as lack of sleep, anxiety, medications like tranquilizers, antidepressants, and some blood pressure drugs, an underactive thyroid, alcohol, depression among others.”

For one to be considered to be suffering from dementia, at least two of the following core mental functions must be significantly impaired: memory, communication and language, ability to focus and pay attention, reasoning and judgment and visual perception.

The WHO says dementia affects each person in a different way, depending upon the impact of the disease and the person’s personality before becoming ill. The signs and symptoms linked to dementia can be understood in three stages; the early stage, the middle stage and the late stage.

However, given that dementia is a progressive condition, where symptoms start out slowly and gradually get worse, it was discovered that it is easy for a person to dismiss the early symptoms of dementia which can be very mild.

“This is the first stage of dementia known as mild cognitive impairment where the symptoms of dementia can be confused with those of anxiety and depression. They include; forgetfulness, losing track of the time, as well as becoming lost in familiar places,” says Onyera.

The moment dementia progresses into the middle stage, Onyera  explains,  forgetfulness and confusion grow. It becomes harder for a person to think and remember. Recalling names and faces becomes a problem. Obvious signs in this stage include inability to think, repetitious questioning, inadequate hygiene (needing help with personal care), language difficulty and poor decision-making. Behavior continues to change and can turn into depression and aggression.

In the most advanced stage, people with dementia become unable to care for themselves. They become totally dependent and inactive. They  become unaware of time and place, unable to eat on their own or even swallow the food in their mouth, bathe or groom themselves; even waking up from slumber on their own may become a problem.

Causes and risk factors of dementia

Anything that damages brain cells will cause dementia or increase one’s chances of acquiring it.

Alzheimer’s disease

The exact cause of Alzheimer’s disease is unknown and no cure is available, according to the Alzheimer’s Association.

Although younger people can and do get Alzheimer’s, the symptoms generally begin after the age of 60.

Apart from Alzheimer’s disease, other degenerative diseases that often results in progressive dementia include Parkinson’s disease and Huntington’s disease.

Lyme disease

Lyme disease is an illness spread to humans through the bite of ticks infected with corkscrew-shaped bacteria known as Borrelia burgdorfen. These bacteria can cause neuroberreliosis which can lead to neurological problems including memory issues and what some describe as brain fog thus resulting in dementia in the long run. Lyme disease, if detected early can be easily cured with antibiotics.

Hypothyroidism

Dr. Broda Otto Barnes states in his book, “Hypothyroidism: The Unsuspected Illness,” that a person with thyroid disorders commonly suffers from dementia like symptoms such as difficulty in concentrating at work or performing basic tasks, trouble remembering people’s names or simple words, memory gaps, brain fog or confusion, decreased mental sharpness, feeling of depression, and insanity.

Because the brain uses so much energy, he explains that individuals with hypothyroidism (slowed metabolism and less energy) tend to experience a decline in their mental sharpness – the brain fog and so many of the above symptoms. This implies that thyroid hormones are critical for normal brain functioning. If detected early, he says, patients with hypothyroidism should be treated with adequate doses of I-thyroxine to increase their thyroid function.

Neurosyphilis

“Neurosyphilis results from infection of the brain, and it develops in people who are not treated for syphilis,” says Dr. Onyera.

Syphilis has four stages: primary, secondary, latent, and the tertiary.  In the primary stage, one may not see symptoms or one may just get a non-painful wound in the private parts which may disappear even without treatment. In the secondary stage, these wounds reappear but covering the whole body. In latent stage, these sores disappear and it can take like 10 years without appearing.

And then in tertiary, this is when it attacks the brain and at this stage, it is very hard to treat and heal. When syphilis attacks the brain, it is very hard to reverse the symptoms. Therefore it is better for one to treat syphilis before it reaches its last stage. The clinical feature is characterized by a slow progressive cognitive decline, hyperactivity, hallucinations, short-term memory and behavior changes which are all symptoms of dementia.

HIV

Dr. Olaro says dementia can be the first manifestation of HIV. It all depends on one’s CD4+ count. This can happen fast even before one knows they are HIV positive.

“It is called acute HIV infection,” he says. “One day the person may be healthy but the next day their CD4 count is so low.”

Once the CD4 count falls to less than 200, he explains, HIV is going to attack the brain through damaging the nerve cells directly or by infecting inflammatory cells in the brain and spinal cord. HIV may then induce these cells to damage and disable nerve cells.

Risk factors

Several factors can increase a person’s risk for developing dementia. As disclosed by the Alzheimer’s Association, it is important to understand that a risk factor is not a cause for example, diabetes is a risk factor for both Alzheimer’s disease and Vascular dementia, but that does not mean it causes Alzheimer’s disease or Vascular dementia. Not all people with diabetes develop dementia. Some factors are reversible if treated or prevented while others are not.

Medical factors

Medical factors include: atherosclerosis, homocysteine, diabetes, obesity, uncontrollable high blood pressure, mild cognitive impairment and Down syndrome.

Atherosclerosis is the thickening and hardening of artery walls due to plaque buildup. Plaque is made of cholesterol, fat, calcium and other substances in the blood. This build up, according to Dr. Onyera, can narrow the arteries and interfere with the flow of blood to the brain. This  impairs the ability of the brain cells to function properly which can also ultimately lead to the death of these brain cells and their connections to other brain cells.

Diabetes, obesity and Down syndrome also being a risk factor for atherosclerosis and stroke can be associated with an increased risk of one developing both Alzheimer’s and vascular dementia.

When it comes to homocysteine, the Alzheimer’s Association reveals that this amino acid naturally circulates in a person’s blood and is a building block of protein. A high level of homocysteine is a risk factor for a number of diseases, including Alzheimer’s disease, vascular dementia, cognitive impairment, and stroke because it can reduce or cut off blood flow to the brain.

For mild cognitive impairment (MCI), this can be thought as a stage between normal forgetfulness and dementia. However, if a person has MCI, Dr. Onyera says it does not mean someone will develop Alzheimer’s but most cases of Alzheimer’s disease start with MCI.

Age

“The risk of developing Alzheimer’s disease, vascular dementia and other types of dementia increases with a person’s age especially after the age of 65,” said Dr. Onyera.

But this does not mean that whoever ages will develop dementia according to the Alzheimer’s Association. In fact, some younger people, in their 40s or 50s, are diagnosed with the early onset form of  dementia.

Aging can impair the body’s self-repair mechanisms, including in the brain. And, many of the cardiovascular risk factors such as high blood pressure, heart disease, and high cholesterol increase with age.

Family history

“Those who have a parent, a brother, sister or child with Alzheimer’s disease are more likely to develop the disease,” states the Alzheimer’s Association. The risk increases if more than one family member has the illness. When diseases run in families, it reports that it is either due to hereditary (genetics) or environmental factors or both. Many forms of dementia have a genetic component and it often runs in families. Symptoms of dementia by genetics nearly always develop before the age of 60 and may appear as early as a person in their 30s or 40s.

Smoking

Smokers have a 45% higher risk of developing dementia than non-smokers, according to the WHO. The more a person smokes, the higher the risk, and it’s estimated that 14% of Alzheimer’s disease cases worldwide are potentially attributable to smoking.

Drinking alcohol

Researchers from Oxford and Cardiff Universities who did a study of more than 13,000 adults found men and women who drank just over one unit of alcohol a day-around half a 175ml glass of wine or half a pint of beer suffered a noticeable decline in their brains’ ability to function over four years. They say adults who drink more than this amount are putting themselves at ‘significant risk’ of dementia. They cautioned people to stop drinking even if it is to calm their nerves.

Depression

Depression is a psychological factor that may put someone at a high risk of developing dementia. However, experts are still puzzled at the relationship between depression and dementia. While depression is a risk factor of dementia, many researchers have discovered that it may as well be an early symptom of the disease.

In her first theory on the relationship between depression and dementia, Ashley Gorman, clinical neuropsychologist with the Morris Psychological Group in New Jersey, revealed that the onset of dementia could actually be the cause of depression given the confusion and loss of memory it creates making a person helpless.

Her second theory holds that depression may directly damage the brain, leading to dementia. She explains that chronic stress and depression may result in the release of cortisol, a stress hormone that can harm the brain over time.

A third theory points to reduced brain volume. According to Paul Schulz, an associate professor of neurology at the University of Texas Medical School, Depression may alter brain volumes, which puts a person at increased risk of earlier symptoms of dementia. He urges people with symptoms of depression to pursue treatment even if their symptoms are not disabling

Treatment for depression may include medications or behavioral therapy. The goal, according to Dr. Schulz is to shorten the depression in the hope of reducing the risk for dementia.

Head injuries

People who experience severe or repeated head injuries are at increased risk of developing vascular dementia. Injuries to the brain normally damage blood vessels which cut off blood supply to the brain or injuries may cause blood to pour into the brain thus damaging it.

Vitamin B12 deficiency

In his Nutrition research report, “Metabolic B12 deficiency: a missed opportunity to prevent dementia and stroke,” Dr. David Spence discovered that dementia is both a cause and a result of vitamin B12 deficiency.

Food intakes tend to decline as dementia progresses, and even in early dementia, patients may lack the initiative to reach out to health care providers that may be able to help diagnose vitamin B12 deficiency. In addition, he says, Vitamin B12 deficiency is a cause of dementia, and contributes to stroke risk. Vitamin B12 supplements are able to reduce plasma homocysteine concentrations by 7 percent.

Prevention

Dr. Onyera says one has to look at the predisposing factors or the risk factors that can be reversed. This involves managing blood pressure or heart problems, managing diabetes, creating an exercise regime to fight obesity, avoiding smoking and alcohol, management of depression and avoiding isolation, eating a healthy diet and engaging in brain challenging activities such as reading.

Many experts believe that controlling cardiovascular risk factors may be the most cost effective and helpful approach to protecting brain health. Because of the known cardiovascular benefits, a medically approved exercise program is valuable.

Like exercise, diet may have its greatest impact on the brain health through its effect on heart health. The best current evidence suggests that heart healthy eating patterns, such as the Mediterranean diet also may help protect the brain. A Mediterranean diet includes relatively little red meat and emphasizes whole grains, fruits and vegetables, fish and shellfish, and nuts, olive oil and other healthy fats.

Head trauma

There may be a strong link between serious head injury and future risk of Alzheimer’s disease especially when trauma occurs repeatedly or involves loss of consciousness. Experts advise people to protect their brains by buckling seat belts, wearing helmets when participating in sports and “fall-proofing” their home where necessary.

Diagnosis of Dementia

Given that dementia is progressive, it is hard to diagnose it. A lot of observation and investigation has to be done to prove that one is suffering from dementia and also rule out other causes of memory loss that are not dementia related.

Dr. Olaro says that a thorough evaluation that involves looking carefully at a patient’s history, conducting a physical and neurological examination which involves a mental status testing, laboratory tests such as blood tests and brain imaging and also observing a patient’s characteristic changes in thinking and behavior must be done.

Authored by Diana Bauza

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