There are different types of dementia, such as vascular dementia and Alzheimer’s disease.

 

What Is Dementia?

Dementia is a disorder of the brain that is characterised by progressive worsening of memory and intellect (cognitive abilities), orientation and personality. Dementia affects a person’s ability to think, reason, remember, learn new information and skills, solve problems and make judgements. It results in a progressive worsening of the affected person’s work, daily activities and ability to interact socially.

How Common Is It?

The risk of dementia increases with age. There are about 22,000 people with dementia in Singapore. This is expected to increase to almost 53,000 in 2020, due to Singapore’s rapidly ageing population.

What Causes Dementia?

There are many causes of dementia. They can be divided into irreversible and potentially reversible:

  • Irreversible causes: e.g. Alzheimer’s Disease, Stroke, Parkinson’s Disease
  • Potentially reversible causes: e.g. Hypothyroidism (a disease in which there are low levels of thyroid hormones), Vitamin B12 Deficiency, Alcohol-related syndromes.

Dementia which is potentially reversible may be curable. Dementia due to irreversible causes cannot be cured. However, it may be possible to slow down the progression by treating any risk factors. It may also be possible to treat the cognitive symptoms. 

What About People With Vascular Dementia?

Vascular dementia is a type of dementia that is caused by a series of small strokes. You can reduce your risk of stroke and therefore prevent vascular dementia by:

  • Visiting your doctor regularly for checks on blood pressure, blood glucose (sugar) and cholesterol
  • Controlling your medical condition (hypertension, diabetes mellitus, high blood cholesterol) effectively
  • Managing your weight
  • Eating a balanced diet and avoiding foods high in salt and fat
  • Engaging in regular exercise
  • Reducing your stress level
  • Avoiding excessive alcohol intake
  • Quitting smoking

What Are the Signs and Symptoms?

The signs and symptoms of dementia include the following:

  • Memory loss (forgetfulness) that occurs gradually and worsens progressively with time. Immediate and short-term memory loss occurs first
  • Difficulty in communication and finding the right words
  • Problems recognising familiar faces or items
  • Worsening of general problem-solving abilities with work and becoming more disorganised
  • Problems with daily activities and familiar tasks such as buttoning of the shirt or blouse, dressing and use of utensils during mealtimes

In addition, the following behavioural and psychological symptoms may also occur:

  • Depression
  • Agitation
  • Hallucinations
  • Anxiety
  • Paranoia
  • Sleep problems

How Is Dementia Evaluated?

The family doctor should first be consulted if any symptoms of dementia are noticed. If dementia is suspected, the doctor will screen further by using special questionnaires. For some, referral to a clinical psychologist or psychiatrist may be required for further assessment.

Various tests may be conducted to identify possible cause(s) of dementia as well as check if there is any other condition that could be causing the symptoms. The tests will be conducted after discussion with the affected person, family members or caregivers and these include:

  • Blood tests (e.g. blood sugar level, thyroid function test, vitamin B12 level in the blood)
  • Neuroimaging tests such as Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI) of the brain 

After the diagnosis of dementia, the attending doctor will do further assessments which include:

  • Asking the affected person, the family members or caregivers for symptoms suggestive of depression, anxiety, agitation, paranoia, hallucinations or sleep problems (using specially designed questionnaires)
  • Assessing the affected person's capabilities in self-care and functioning at home and in social settings
  • Discussing with the family members or caregivers regarding possible caregiving or financial difficulties. This will enable the doctor to refer the family members or caregivers to the appropriate community agencies for help, if necessary

How Is Dementia Managed?

The management of dementia usually involves one or more of the following 5 aspects:

1.Treatment of reversible causes and risk factors

This may involve:

  • Treatment of any reversible causes that have been identified (e.g. treatment for Hypothyroidism, replacement of Vitamin B12 in patients with B12 deficiency)
  • Reduction of any risk factors for stroke that may have been identified (e.g. treatment of diabetes mellitus, hypertension, high blood cholesterol, etc.)
  • Use of medications for stroke prevention (e.g. aspirin)

2.Medications to slow the progression of dementia

At present, there are no recommended medications. Vitamin E may give rise to a slight improvement, but its safety in the high doses required is as yet uncertain. 

Medication can improve the cognitive symptoms of Alzheimer's disease but cannot cure dementia.

3.Medications to improve the cognitive symptoms in Alzheimer’s Disease

These medications help to improve the cognitive symptoms in those with Alzheimer’s Disease:

  • Acetyl Cholinesterase Inhibitors (AchEI) (which prevent the breakdown of the enzyme acetylcholine, an enzyme which is found in lower than normal levels in those with Alzheimer’s Disease) e.g. Donepezil, Rivastigmine, Galantamine
  • N-methyl D-aspartate (NMDA) antagonists (which prevent cell damage from glutamate, a chemical present in excessive amounts in those with dementia) e.g. Memantine

Generally, these medications are well tolerated. Possible side effects include:

  • AchEI: nausea, vomiting, diarrhoea and anorexia
  • NMDA antagonists: dizziness, headache, fatigue, hallucinations and confusion 

Please also remember that:

  • These may not work for everyone
  • These are expensive
  • These do not cure dementia
  • Although there may be a slight improvement or stabilisation of symptoms, these ultimately do not prevent the disease from getting worse

 symptoms, these ultimately do not prevent the disease from getting worse

4.Managing Behavioural and Psychological Symptoms of Dementia (BPSD)

Behaviour problems are usually a cause for major stress among family members or caregivers. Managing BPSD involves non-medication measures (involving a multi-disciplinary team) as well as the use of medications.

Non-medication measures include:

  • Environmental modification to provide a safe & friendly environment
  • Structured activity programmes and rehabilitation therapy
  • Social contact/interaction
  • Psychological therapy
  • Others 

Medications used in the management of BPSD include:

  • Anti-depressants
  • Anti-psychotics
  • Others

The attending doctor will discuss with the family members or caregivers regarding any decision to start the affected person on medications to manage BPSD.

Non-medication measures should generally be considered as the first step in managing those with BPSD. Using medications to treat BPSD carries the risk of side-effects and may mask or suppress behaviour that actually allows the person with dementia to communicate his or her needs.

5.Social support and support for caregivers

Support for the person with dementia as well as the family members and caregivers is important as it allows appropriate care to be provided. These support services include:

  • Education sessions on dementia and caregiver skills
  • Individual and family counselling
  • Regular caregiver support group meetings
  • Sessions with healthcare professionals and counsellors who can provide support and help with crises and the changing nature of the affected person’s symptoms
  • Respite care for the affected person
  • Web-based learning, on-line discussions, etc.

The attending doctor or healthcare professional may also refer family members or caregivers to community resources to meet various care needs. Examples of such community resources include:

  • Meal-on-wheels service
    • Home nursing service
    • Home medical service
    • Dementia daycare service
    • Others

Are There Any Other Issues to Consider?

1.Driving

Driving represents independence, freedom and mobility for a person. However, if driving compromises the affected person’s safety and public safety, the attending doctor may enlist the help of the family members and caregivers to persuade him or her to stop driving.

2.Restraints

Restraints (environmental, physical, etc.) are sometimes used in order to restrict or control the affected person’s movement when he or she is assessed to be dangerous to himself or herself or others. Such restraints should only be used as a last resort and only as a temporary measure. Restraints should be removed as soon as possible and excessive use must be avoided. 

The use of restraints can be harmful. They can cause:

  • Direct harm and injury
  • Loss of independence
  • Loss of freedom, leading to loss of confidence and self-esteem

3.Living alone

Many people diagnosed with dementia continue to insist on living alone. This can affect their safety and well-being and also exposed them to mistreatment, fraud and exploitation by others.

The attending doctor will assess whether someone with dementia is capable of living alone.

For more information and a list of community resources, download “Your Guide to Understanding Dementia” (PDF), available in four languages.

 

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