Reflections on treating dementia

20 May 2019

Interview with 

Isabelle Cochrane, trainee doctor

DOCTOR

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Dementia is an umbrella term for a number of conditions, and worldwide, around 50 million people have it. To sift through the science of this group of conditions and to reflect on her experiences caring for dementia patients, here’s trainee doctor Isabelle Cochrane.

Something is happening to Mrs Jones. She loses her train of thought and her daughter tells her that she keeps asking the same questions over and over. Cooking dinner has become a nightmare. She gets muddled when the recipe involves more than a couple of steps. Yesterday, she got lost on her way to the bakery despite living in the same neighbourhood for the past 40 years. But this is just the beginning.

These subtle changes will gradually evolve meaning that eventually she won't know the time of day or the day of the year. Her home will feel unfamiliar, unsafe, and confusing and her family may notice her become more aggressive or even violent. Losing her mild manner, she may start saying and doing alarming things that she never previously would. By now, you may have guessed that Mrs Jones is suffering from dementia.

This is a term we hear a lot, but it can be tricky to put a finger on exactly what dementia is. One thing that is important to understand is that dementia is not a single disease but rather something called a clinical syndrome. In other words, it is a collection of symptoms that tend to appear together in an identifiable pattern. So, along with a memory loss that most people would associate with dementia, we also get other characteristic changes. People lose the ability to plan ahead effectively and may find it hard to concentrate. Decreased spatial awareness makes it hard to navigate even familiar environments and there is often also a decrease in verbal fluency.

People suffering from dementia may also have changes in their personality. Showing what we call this inhibition they find it difficult to control their behaviour and may act in ways that most of us would consider socially unacceptable. So, what does these processes can lead to these cognitive changes that we call dementia. By far the most common cause is Alzheimer's disease. It is not entirely clear how the disease comes about. But what we do know is that when the brains of people with Alzheimer's are examined at post-mortem, abnormal protein fragments called amyloid plaques are seen. As these plaques are deposited in the brain, it is believed that they cause inflammation. Inflammation is a generic term which describes the response of the immune system to entities that are recognized as being foreign or harmful to the body. This process of inflammation leads to the neurons in the brain behaving abnormally which, in turn, is thought to result in the characteristic changes in brain function that we see.

Alzheimer's disease accounts for over half of all dementia cases. Another very common cause is vascular dementia which accounts for about another quarter of cases. Here blood is unable to reach all areas of the brain normally. This is usually due to changes in the blood vessels which may occur when factors such as blood pressure, cholesterol, and blood sugar are poorly controlled. Over time, this abnormal blood supply causes multiple small strokes. This results in neurons dying, once again causing changes in cognitive function.

Aside from vascular dementia and Alzheimer's several other types of dementia also exist but these are generally much more uncommon. Sometimes several different types of dementia may coexist. It can be difficult to differentiate between the different forms of dementia, although often the exact pattern of cognitive changes is subtly different in each type. In order to arrive at a diagnosis, doctors will initially perform a cognitive test, a little like a long questionnaire which allows the various functions of the brain to be measured in a reasonably objective way. This will sometimes then be followed by a scan of the brain which may reveal which areas are most severely affected. The cognitive test and the results of any scans are used in combination to make a diagnosis of dementia and to work out which disease is underlying the process. If Alzheimer's disease is thought to be the cause, certain drugs can be given. In other cases, there is very little to be gained from giving medications.

In all types of dementia focus is given on trying to keep the brain active through programs run by specialist therapists. Unfortunately, however, the outlook for people with dementia is still quite poor with little that can be done to slow its progression. The average life expectancy is around seven years but of this time much will be lived with severe disability and dependence on the care of others. With the number of cases of dementia set to increase to over 2 million by 2050 in the UK alone, learning to manage this condition effectively is rapidly becoming a priority for doctors and healthcare systems alike.

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