[Alandriel (OP)]

My father in law will be released from hospital this coming weekend following a successful hip surgery (not replacement) after a fall at home. He is 88 and although thin and frail quite in good shape. At least that’s the doctors verdict after many proddings and extensive tests.

He forgets – which is not surprising considering that some form of dementia does affect 20 out 100 people in his age group and the doctors have confirmed it.

I only wonder sometimes just how much is real dementia and how much is just – and forgive me for being candid – the behaviour of a crafty, manipulative old man.

You see, he pretty much has everyone wrapped around his little finger and behaves like the patriarch he his. Unfortunately that is to a large extent a cultural thing and most probably won’t change – at least we have not found a way yet.

How to tell how much of the dementia is real and how much is contrived?

There seems to be no logic, no real pattern in what he does remember and what he forgets. It all seems to be on a whim, totally erratic…. and quite frankly it’s really driving us all slowly but surely nutts.

Do you have any experience with this or any help / advise you could offer?

Thanks

[rosalind dna]

Yes, I have an aunt who's had dementia for about 10 years now and she can't
remember her sons, grandsons and their respective families. But she can't
even recognise my father.
She was a doctor once. now she has to be fed, washed and basically cared for
like a baby does. it's sad.

[Carolyn]

Alandrial, this sounds EXACTLY like my father.  He's 66 and behaves the same way, except he also can be the meanest SOB that ever existed.  I've thought the same things that you've been wondering.  My mother says it's because of the medications that he's on, and I think that may be a small part of it, but I really do feel like a great deal of the time he is being manipulative.

He's always had me wrapped around his finger, as well as my mother and I have always been the typical "Daddy's girl". Lately though, it's getting very difficult for me to be around him.  I cannot tolerate the way he speaks to my mother or to me.  He was overbearing before he had health issues, but it's worse now.  He has an angioplasty scheduled for next week and I'm not looking forward to having to deal with the abuse he heaps out.

[another_someone]

It is common for people with dementia to get more aggressive.  In part, it must be very frightening for them as they feel they are losing control of their world, and no longer fully understand what is going on around them, so they panic.  Ofcourse, the panic probably only makes matters worse, as they are even less able to remember things than when they can remain calm.

Again, dementia, like all chronic illnesses, will come and go, so there will not be a clear pattern.

[iko]

We discussed rare cofactors deficiencies in reversible dementia with Zoey, few months ago:

http://www.thenakedscientists.com/forum/index.php?topic=7457.msg103748#msg103748

Whether our elderly relatives need vitamin B12 or not,
to keep their brain in good shape is still a matter of
debate.  Negative reports prevailed in the past, now
times are changing a bit.
This is a positive report from Israel.
I find it sharp and encouraging indeed...
If only a few patients respond to a treatment, we have
to identify their 'size and shape', instead of throwing
the whole research in the garbage bin.

Neuropsychology of vitamin B12 deficiency in elderly dementia patients and control subjects. [/b]

Osimani A, Berger A, Friedman J, Porat-Katz BS, Abarbanel JM.Kaplan Hospital, Rehovot, Israel and the Department of Behavioral Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.

Cobalamin deficiency may cause cognitive deficits and even dementia. In Alzheimer's disease, the most frequent cause of dementia in elderly persons, low serum levels of vitamin B12, may be misleading. The aim of this work was to characterize the cognitive pattern of B12 deficiency and to compare it with that of Alzheimer's disease. Nineteen patients with low levels of vitamin B12 were neuropsychologically evaluated before treatment and a year later. Results were compared with those of 10 healthy control subjects. Final results suggest that there is a different pattern in both diseases. Twelve elderly patients with dementia improved with treatment. Seven elderly demented patients did not improve; they deteriorated after 1 year although their levels of cobalamin were normal. Analysis of the initial evaluation showed that the 2 groups of patients had a different neuropsychological profile. The group that improved had initially more psychotic problems and more deficits in concentration, visuospatial performance, and executive functions. They did not show language problems and ideomotor apraxia, which were present in the second group. Their memory pattern was also different. These findings suggest that cobalamin deficiency may cause a reversible dementia in elderly patients. This dementia may be differentiated from that of Alzheimer's disease by a thorough neuropsychological evaluation.

J Geriatr Psychiatry Neurol. 2005 Mar;18(1):33-8.

http://content.answers.com/main/content/img/McGrawHill/Encyclopedia/images/CE734300FG0010.gif

I'm probably wrong when I suggest to check vitamin B12 levels whenever the nervous system is 'touched'.   May be it is a waste of time and money, like a lottery: very few patients win a diagnosis of reversible dementia.

[iko]

Importance of vitamin B12 is being revisited
after long years of criticism and hostility.
Not a 'tsunami' effect like with vitamin D,
only a correct re-evaluation of its qualities.
This is one of many recent positive reports:

Vitamin B12, folic acid, and the nervous system.

Reynolds E.
Institute of Epileptology, King's College, Denmark Hill Campus, Cutcombe Road, London, SE5 6PJ, UK. reynolds@buckles.u-net.com

There are many reasons for reviewing the neurology of vitamin-B12 and folic-acid deficiencies together, including the intimate relation between the metabolism of the two vitamins, their morphologically indistinguishable megaloblastic anaemias, and their overlapping neuropsychiatric syndromes and neuropathology, including their related inborn errors of metabolism. Folates and vitamin B12 have fundamental roles in CNS function at all ages, especially the methionine-synthase mediated conversion of homocysteine to methionine, which is essential for nucleotide synthesis and genomic and non-genomic methylation. Folic acid and vitamin B12 may have roles in the prevention of disorders of CNS development, mood disorders, and dementias, including Alzheimer's disease and vascular dementia in elderly people.

Lancet Neurol. 2006 Nov;5(11):949-60.

Preventing Age-Related Cognitive Decline
By Laurie Barclay, MD

...
Replacement of B vitamins in deficient individuals often improves short-term memory and language skills. Elderly subjects who are low in folic acid show impairment in both word recall and object recall, suggesting a vital role for folic acid in memory function in later life. Memory impairment in the elderly related to vitamin B12 deficiency can be reversed by vitamin B12 injections or supplements.
High doses of vitamin B6 and folate reduce blood levels of homocysteine, a toxic buildup product linked to heart disease and cognitive impairment. In dementia patients with even mild deficiencies of vitamin B12 or folate, replacement can improve cognition, especially in those with elevated blood homocysteine levels. In a study of 76 elderly males, vitamin B6 was better than placebo in improving long-term information storage and retrieval.

http://www.lef.org/magazine/mag2005/images/apr2005_cover_cognitive_04.jpg

Life Extension Magazine - April 2005    http://www.lef.org/magazine/mag2005/apr2005_cover_cognitive_02.htm 
 

[iko]

Vitamin B12 deficiency could cause pernicious anemia and/or severe neurologic damage, psychotic behaviour and in rare cases irreversible blindness.  I remember a report of few years ago about a young man left completely blind after a badly managed vegan diet.

iko

Dementia caused by vitamin B12 deficiency. Clinical case
[Article in Spanish]

Behrens MI, Diaz V, Vasquez C, Donoso A.
Departamento de Neurologia y Neurocirugia, Hospital Clinico Universidad de Chile.

Cyanocobalamin (vitamin B12) deficiency can cause polyneuropathy, myelopathy, blindness, confusion, psychosis and dementia. Nonetheless, its deficiency as the sole cause of dementia is infrequent. We report a 59 years old man with a 6 months history of progressive loss of memory, disorientation, apathy, paranoid delusions, gait difficulties with falls, and urinary incontinence. He had suffered a similar episode 3 years before, with a complete remission. On examination there was frontal type dementia with Korsakoff syndrome, a decrease in propioception and ataxic gait. Cerebrospinal fluid examination showed a protein of 0.42 g/L. Brain computed tomography showed sequelae of a frontal left trauma. Brain single photon computed tomography (SPECT) was normal. Complete blood count showed a macrocytic anemia with a hematocrit 29% and a mean corpuscular volume of 117 micron3.
Plasma vitamin B12 levels were undetectable, erythrocyte folate levels were 3.9 ng/ml and plasma folate was normal. The myelogram showed megaloblastosis and the gastric biopsy showed atrophic gastritis. Treatment with parenteral B12 vitamin and folic acid reverted the symptoms, with normalization of the neuropsychological tests and reintegration to work.

Rev Med Chil. 2003 Aug;131(:915-9.

I forgot to explain how vitamin B12 deficiency could develop even on a regular diet.
Gastric atrophy leads to impaired production of a special protein (Intrinsic Factor) that binds B12 and allows its absorption in the intestine.
Liver can stock large amounts of B12 enough for approx. 6 months.
So if the stomach stops making IF, after 6m on a regular diet vitamin B12 deficiency becomes evident (to whom can diagnose it on the spot!).  Large amounts of B12 taken by mouth allow the intestine to absorb enough vitamin anyway.  But in case of severe deficiency, parenteral administration for a few days is recommended.
bye

iko

Vitamin D Deficiency Is Associated With Low Mood
 and Worse Cognitive Performance in Older Adults.

Wilkins CH, Sheline YI, Roe CM, Birge SJ, Morris JC.

Dept.Med.Div.Geriatrics and Nutritional Science, Alzheimer's Disease Research Center, the Dept.Psychiatry, Dept.Neurol., and the Div.Biostatistics, Washington Univ.School of Medicine, St. Louis, MO.

Background: Vitamin D deficiency is common in older adults and has been implicated in psychiatric and neurologic disorders. This study examined the relationship among vitamin D status, cognitive performance, mood, and physical performance in older adults.

Methods: A cross-sectional group of 80 participants, 40 with mild Alzheimer disease (AD) and 40 nondemented persons, were selected from a longitudinal study of memory and aging. Cognitive function was assessed using the Short Blessed Test (SBT), Mini-Mental State Exam (MMSE), Clinical Dementia Rating (CDR; a higher Sum of Boxes score indicates greater dementia severity), and a factor score from a neuropsychometric battery; mood was assessed using clinician's diagnosis and the depression symptoms inventory. The Physical Performance Test (PPT) was used to measure functional status. Serum 25-hydroxyvitamin D levels were measured for all participants.

Results: The mean vitamin D level in the total sample was 18.58 ng/mL (standard deviation: 7.59); 58% of the participants had abnormally low vitamin D levels defined as less than 20 ng/mL. After adjusting for age, race, gender, and season of vitamin D determination, vitamin D deficiency was associated with presence of an active mood disorder (odds ratio: 11.69, 95% confidence interval: 2.04-66.86; Wald chi(2) = 7.66, df = 2, p = 0.022). Using the same covariates in a linear regression model, vitamin D deficiency was associated with worse performance on the SBT (F = 5.22, df = [2, 77], p = 0.044) and higher CDR Sum of Box scores (F = 3.20, df = [2, 77], p = 0.047) in the vitamin D-deficient group. There was no difference in performance on the MMSE, PPT, or factor scores between the vitamin D groups.

Conclusions: In a cross-section of older adults, vitamin D deficiency was associated with low mood and with impairment on two of four measures of cognitive performance.

Am J Geriatr Psychiatry. 2006 Dec;14(12):1032-1040.

[Alandriel (OP)]

Thanks guys. Your input is really very much appreciated. []



Rosalind: that’s very sad and undoubtedly very difficult to deal with. Thankfully we’re not at such a state of deep dependency yet though if dad keeps refusing to try and walk after his operation we’ll soon get there I fear.



Carolyn: at least I don’t have quite the emotional baggage as my husband and mom-in-law have. Though I’m very close to the whole family I’m also an ‘outsider’ – if you know my meaning – an thankfully so. I see what it does to my husband and mom to deal with dad. Not easy and not pretty at times.
I try to the best of my abilities to help defuse and help them keep level headed, to try to disassociate whenever possible; easier said then done of course. What really gets us all so much is the daily variances and then trying to make out what’s real and what’s manipulation. He can be so charming to a visiting nurse or carer and a total SOB to us only to reverse the whole thing a couple of hours later.



I fully agree with you George on the frightening aspects. It’s been really heart wrenching this week, dad calling my husband in the wee hours of the morning daily from hospital to plead to be taken home. An hour or so later when hubby shows up at the hospital dad either does not remember, or – worst case scenario – does not recognize him.
He momentarily panics, is quickly reassured (thankfully) but then totally forgets and of course the same scenario is repeated over and over again.
He’s got lots of little silly habits and we’re trying to find a way to break them without creating havoc/panics for him. E.g. he dabs his eyes all the time with tissues as if there was an irritation. That constant wiping of course removes a lot of moisture, his eyes get dry and then he applies eye drops. Now imagine that on a continuous basis for sometimes hours on end. His eyes get sore and then he complains of pain with more eyedrops, more tissues…. Take the tissues away he does the same thing but using his fingers; or he starts fidgeting with toothpicks till his gums are sore….
You get the picture. We’ve tried occupying him with other things but trouble is his attention span is very limited and these ‘fidgetings’ seem to be the only ‘familiar/comfortable/comforting’ thing that he reverts to very quickly again. sigh..



Iko: I’m well aware of the nutritional factors and believe me, diet is a major issue with dad. Thanks for taking the time though for listing the B's, B12 in particular and folic acid.
Pre operation we had months of persistent quarrels as he refused almost all food. He barely touched anything though my mom and I went to great length to entice him with this that or the other. He basically only ate what is to him ‘comfort food’ e.g. rice pudding, apple sauce, cookies. Sweet things mostly. He took vitamin supplements but the food refusal situation got overall so bad that the GP put him on a nutritional replacements called ‘Ensure’; basically a liquid food that’s fully balanced with all the necessary nutrients, vitamins and mineral. This despite the fact that blood tests did not reveal any deficiencies. The liquid replacement food made a positive difference (e.g. especially in regards to swollen feed which subsided completely, apparently due to lack of protein), though getting enough calories into him still is a problem.
At the hospital (currently) he’s eating not to badly. Yes, imagine that LOL. It seems he likes hospital food though this morning he flat out refused to eat his breakfast and then got coaxed into what amounts to a teaspoon full of scrambled eggs. I think he's back again to more his 'normal' self.



One of the main issues with dad seems to be (at least this is my current appraisal) that he is all too willing to let people do things for him where once upon a time he was boss, a real do-er and not a deligate-or; one could have called him a control-freak. Seems the pendulum has completely swung the other way.
Now, there is nothing left of that, no initiative, no self motivation, no will. Yet he’s not depressed, rather obsessed with little things / fidgetings …. and he’s driving everyone slowly up the walls.
Next week is going to be interesting……


In the meantime, if anyone has some practical ideas or strategies suggestions – I could use some…

[RD]

Overly emotional behaviour, including emotional blackmail, is a real symptom of dementia ...

Initially in dementia, which begins benignly over months and years, there is memory loss for recent events such as stoves being left on, keys being misplaced, conversations forgotten. Later, people begin to get lost while driving roads that they once knew very well, and questions must be repeated because the questions and answers are quickly forgotten. The long-ago memories are retained and dwelled upon. Personality changes occur, and the person may manifest changes that are the complete opposite from their previous personality. Poor judgement and impulse control often go hand-in-hand. They may speak crudely, make lewd gestures and display their genitals.

The intellectual functions begin to deteriorate, with the patient having trouble naming objects, difficulties understanding language, and their speech can become stereotyped, slow, vague and filled with irrelevant details and they are unable to concentrate and follow a conversation and determine what is relevant and what is not.

They begin to have difficulty with motor tasks such as drawing a house, handling money, using tools to cook, assemble blocks. Patients often deny these problems vigorously, or become ashamed of them, and enter a phase of depression, anxious, and demoralized. They may then begin to show emotional incontinence: respond to situations inappropriately by crying, laughing, hostility, and immobility at inappropriate times. They may confabulate stories to make up for lost memories to conceal the degree of memory loss. Upon examination, these patients generally move slowly and deliberately or fidget, looking glum, bored or tense. On the other side, they may portray a mood of jocularity in which they make inappropriate remarks to members of the opposite sex.

http://www.mental-health-matters.com/articles/article.php?artID=57

[another_someone]

I think much of the problem is not only about the situation your father is in, but in the situation you and your family are in with regard to your father.

You probably do not recognise it, but I suspect that the family is having to go through a slow, very slow, and prolonged and painful, grieving process for the person who was your father.  It leaves you in an impossible situation, because you cannot formally grieve for someone who, in body, is still alive; yet the person inside is becoming ever more distant from the person with whom you have evolved the relationships that defined who your father in law was to you, and your husband's father was to him.

You are still having to care for this man, and yet the established relationships by which you would have cared for him in the past are receding, so you have to find a way of relating to him as he is, which is different from relating to him as he was.

I am not saying you should just accept the inevitable without trying to do what is physically best for him, but you also have to look inside yourselves, and find a way of dealing with your own (as a family) emotional turmoil, not only with his physical needs.

[Alandriel (OP)]

Sorry I haven't been able to keep up in here. We've had a very tense 3 days.

He finally passed away in the early hours of this morning....





I won't be able to log in here for a while but I'll be checking emails. Thanks friends

[Carolyn]

Sorry I haven't been able to keep up in here. We've had a very tense 3 days.

He finally passed away in the early hours of this morning....





I won't be able to log in here for a while but I'll be checking emails. Thanks friends

I'm so sorry to hear this sad news.

You're all in my thoughts and prayers.

[Karen W.]

Sorry I haven't been able to keep up in here. We've had a very tense 3 days.

He finally passed away in the early hours of this morning....





I won't be able to log in here for a while but I'll be checking emails. Thanks friends

Alandriel, I am so sorry about this. my best to you and yours. Big Big Warm Hugs...take care of yourselves.

Best wishes and many prayers...

[iko]

I'm sorry Alandriel,

everything seems to have precipitated so fast,
suggesting more an acute disease than the sadly
well known slowly progressing dementia.