GERIATRIC DEPRESSION & ANXIETY

Depression and anxiety are common geriatric disorders that have a negative effect on a person’s balance (clumsy, unsteady), movement (involuntary movements like tremors can occur), and speech (racing thoughts and faster speech). Other aging issues, such as loss of taste, hearing, or smell, can be problematic, especially for seniors living alone. Deterioration in these vital senses makes older people increase the chances of accidents leading to more injuries. Depression is one of the risk factors for CVS disease, and it has been related to higher mortality rates. In addition, successful care of the main problem, who should undertake efforts to improve patients’ psychological and social function, and more efforts should be put into improving issues related to the mental and emotional state of the person and relation to society’s function.

There are several warning signs and symptoms of depression, such as persistent sadness, anxiety, or sorrow, undiagnosed aches and pains that don’t go away with medication, sudden appetite loss or weight loss, low motivation or energy, trouble falling asleep or staying awake, suicidal thoughts or prior suicide attempts, memory problems, forgetfulness, or difficulty making decisions.

What is Dementia?

The most common cognitive health issue facing the elderly is Dementia in India. Globally, 47.5 million people have dementia, and this number is predicted to nearly triple by 2050. Chronic health conditions and substance abuse, such as diabetes, hypertension, depression, HIV, and smoking, increase the risk of developing dementia.  Dementia as a term refers to a variety of symptoms resulting from damage to brain cells, which alters the ability of the brain to perform its regular activities. Different illnesses cause this damage to occur in different patterns, which in turn produce unique symptoms.These patterns correspond to the different types of dementia, for e.g Alzheimer’s disease, dementia in Lewy bodies etc.

Common signs of Dementia

Dementia usually occurs among the elderly population (aged 65 and above). If an individual younger than 65 is diagnosed with dementia, it is called ‘early-onset’ dementia and is quite rare.

• Memory loss and thinking difficulties
• Difficulty coping with daily tasks and functioning independently
• Language & communication difficulties
• Changes in mood, judgment or personality

Though memory loss generally occurs in dementia, memory loss alone doesn’t mean you have dementia. For a diagnosis of dementia, at least one more of the following core mental functions must also be significantly impaired to be considered dementia:

• Communication and language
• Ability to focus and pay attention
• Reasoning and judgment
• Visual perception
• Orientation and comprehension

Early vs Advanced Symptoms of Dementia

• Memory difficulties: Misplacing important items like keys, wallets, official documents etc.; forgetting day/date/year/month or important events like festivals and birthdays; making lists to remember things; forgetting recipes if they regularly cook and so on
• Subtle language and communication difficulties:Such as searching for words during conversations; forgetting or mixing up names of people, objects or places; using the wrong word during conversation; making minor grammatical errors and so on
• Difficulty planning, making decisions, solving problems: Being unable to carry out tasks involving many steps which they otherwise usually can; unable to pay attention to many things simultaneously; giving up responsibilities to others and refraining from being involved in planning events like weddings or festivals and so on.
• Being moody: Being easily irritable, low frustration tolerance, crying spells, temperamental or aggressive – more than usual
• Becoming inactive and being disinterested in any activity: (losing interest in activities they usually took part in, being withdrawn, less sociable and so on.
• Needing help with some of the activities that they were able to do independently previously: Such as starting to get overly dependent on other family members for complex tasks that involve a lot of thinking; struggling with tasks that are new and involve learning; struggling with managing finances as well as they used to and so on

In the later stages of the diseases, a Person with dementia may experience –

• Decline in independent day to day functioning – bathing, dressing, eating, shavingand so on
• Further memory decline – Beginning to forget name of spouse, name of children, misrecognizing familiar people, forgetting their address, phone number or familiar places, being repetitive in conversations
• Wandering – getting lost, leaving the home unexpectedly despite being asked not to
• Will most likely need care provided by others for all day to day activities
• May be unable to recognize people (including close family and friends), or familiar places (their own home or neighborhood)
• May experience bladder and bowel incontinence
• May display little to no communication or language abilities
• May be mostly bed bound

Common difficulties with dementia

Each person is unique and experiences dementia in their own way. The way people experience dementia depends on many factors, including physical make-up, emotional resilience and the support available to them. On a general note, people with dementia may have problems with short-term memory (or remembering things that have happened in the recent past), keeping track of personal items and belongings, paying bills, preparing meals or carrying out other household activities, finding their way around familiar places, planning and remembering appointments- which can be quite frustrating for them. As the illness progresses the person may loose their ability to perform self-care functions such as bathing, brushing one’s teeth, changing clothes and recognize family and friends.

The illness affects each person differently. It is important to remember what is true of one Person with Dementia (PwD) may not necessarily be true of another PwD.

Types of dementia

In India it was estimated that in 2010 there were 37,00,000 people with dementia and this number will grow to almost 80,00,000 in 2030. That is 5 in 100 people about the age of 65 may have dementia

Common types of Dementia:

• Alzheimer’s disease
• Vascular Dementia
• Dementia in Lewy bodies
• Fronto- temporal dementia

These types of dementia are among the most commonly occurring and account for at least 90% of all cases of the illness. However, it is important to note that the distinctions between these sub-types are not clear in some cases and symptoms may overlap resulting in mixed dementias. Mixed Dementia is observed when more than one cause of dementia can occur simultaneously in a person.

Apart from the above, there are some types of dementia caused by conditions that are often treatable or reversible by timely medical and/or surgical intervention. These include –

• Depression: causes a ‘pseudo-dementia’ which can get better with antidepressants and talking therapies.
• Toxic reactions, like excessive alcohol or drug use
• Nutritional deficiencies, like vitamin B12 and folate deficiency
• Endocrine disorders such as thyroid hormone problems can cause memory problems

It is important to be vigilant of delirium which occurs commonly among the elderly. Delirium occurs when a person due to may have periods of transient confusion or memory loss due to infection and many other physical health problems including constipation or dehydration. Behaviour like this must immediately be referred to a doctor and can be  reversed by initiating appropriate treatments.

Cure vs Prevention of Dementia

There is no cure for Dementia. However, prevention of worsening of the symptoms is possible.

Diagnosis of dementia as early as possible is crucial!

An early dementia diagnosis is beneficial for not just the PwD but also for those will take care of them.For practical purposes, it is important for dementia to be diagnosed in the early stages so that doctors can assess the PwD’s medical situation as accurately as possible and subsequently administer the right treatment to improve their prospects. Apart from this, an early diagnosis means the PwD has the capacity to plan and make appropriate decisions for the future. These could be medical, financial, family-related or even in terms of the kind or support they want to receive during their illness. Also, an earlier assessment and treatment may completely cure some of the other conditions associated with dementia, such as thyroid problems or depression. Psychological interventions can also be provided to extend their current level of functioning as long as possible and reduce the acceleration of their decline or even stabilize them.

For the carer, an early diagnosis of dementia can be very valuable. It will give them time to cope with the news that their loved one will soon start to change. They can have conversations with their loved one about their future and get familiar with their preferences for care. They can also resolve any feelings that might be provoked by the news along with their loved ones. They also have the time to prepare for their eventual role as the care-giver – which can be extremely stressful and demanding (physically, emotionally and socially). They can extend the period of independence of their loved ones which would subsequently reduce a lot of care-giver burden. An early diagnosis also means that the carer doesn’t have to make all important decisions alone; they can involve their loved one as long as they are able to.

Importantly, both the PwD and the carer require time to understand the illness and seek out the best advice and medical care so that they can prepare to face it together.

 Risk factors for Dementia

• Increasing age: The risk goes up with advanced age. The older you are the more at risk you are for developing dementia.
• Hardening and narrowing of arteries:The accumulation of fats and cholesterol in the lining of arteries can hinder blood from getting to the brain, which can lead to stroke or another brain injury.
• Diabetes: People with diabetes appear to have a higher risk for dementia, as it is a well-proven risk factor for stroke and cardiovascular disease-related events, which in turn increase the risk for vascular dementia.
• Hypertension: High blood pressure has been linked to cognitive decline, stroke, and types of dementia that affect the white matter regions of the brain.
  (Diabetes and Hypertension has been known to be quite prevalant in India hence it is paramount to keep it under control as one gets older)
• Down syndrome: Many people with Down syndrome develop early- onset AD, with signs of dementia by the time they reach middle age.
• Genetics:When more than one family member has the disorder, risk increases. Very early onset frontotemporal dementia is found to be genetic.
• Mental illness: Depression has been associated with mild mental impairment and cognitive function decline.
• Substance use:Smokers are prone to diseases that slow or stop blood from getting to the brain.Excessive consumption of alcohol also increases risk of developing dementia.

Management of Dementia

Dementia is a progressive disease. Unfortunately, there is no curative treatment. However, a lot can be done to improve the quality of life of the PwD and their carers if the diagnosis is made early and appropriate measures are put in place to plan for the future, thus avoiding many a crisis.

Medicines currently available for the treatment of some types of dementia can help in slowing down the disease process. They also can help in managing some of the common behavioural challenges such as restlessness, aggression, sleep disturbance, etc. They are best chosen and monitored by physicians who are experienced in managing persons with dementia. Also, it is important to note that some medicines may not be appropriate for certain types of dementia.

Best outcomes for persons with dementia and their carers are achieved with multi-disciplinary, person centred approach involving the family members as well as professionals like dementia trained nurse, psychologists, home care assistants, occupational therapists, physiotherapists etc. Understanding the uniqueness of the person with dementia and exploring the meaning of some of their symptoms often help in identifying right interventions. Good nursing interventions will be necessary in those with more severe condition.

Treatment for Dementia

Some non-drug interventions for dementia include:

1. Cognitive Stimulation: Participating in activities and exercises designed to improve memory, problem-solving skills and language ability especially in group settings that facilitate communication and social interaction
2. Reminiscence: Using the PwD’s past information and stories from their child and young adulthood (which in most cases remain intact) to relate to the present.
3. Validation therapy: Using empathy and listening as the key tools to facilitate well-being in conjunction with talking therapies
4. Functional Analysis: Using rehabilitative techniques to manage aggression, anxiety, delusions and hallucinations, wandering behaviours by understanding the motivation driving the behaviour and tackling it at that level

Other therapies used with people with dementia include Cognitive behavioral therapy to help reduce their day to day distress, Supportive psychotherapy and family therapy to help the family understand and resolve conflicts in a manner that aids the patient and the family as a whole. 

To read more about the treatment and support options DEMCARES offers. 

https://www.dementiaindia.org/demcaremedia/booklets/environment-digest-final.pdf

https://www.dementiaindia.org/demcaremedia/booklets/healthproblems-final.pdf