DEMENTIA: THE "MIND-SNATCHER".

Dementia not only affects a patient's memory; it also interferes with cognitive functions and the ability to make sound judgments. It essentially deprives and robs its victims of the very essence of their personalities. Dementia strikes at the heart of a patient's individuality and snatches the mind.

People who were once "clever"--able to make sense of complicated issues and reach sound decisions--become unable to make even very simple determinations. Those who once were caring, compassionate, and loving, gradually become demanding, rude, and oblivious to the needs and feelings of others. As the dementing illness worsens and takes a firm hold on patients' minds, they may become obnoxious, aggressive, and even violent. Ironically, although the patient's mind is severely affected, the physical capabilities are barely affected until the very late stages of the disease. It is as if a completely different person inhabits the victim's body. It is the same body, but where has the mind gone? Dementia truly snatches the minds from its victims!

Dementia is usually a slowly progressive illness. The patient's family and loved ones have no option but to watch the relentless deterioration. How they wish there was something they could do! Instead, helpless, they are forced to witness the mind of their loved one gradually decline and be replaced with the mind of someone they do not know. In front of their very eyes Dr. Jekyll is transformed into Mr. Hyde! To make matters worse, every now and then there appears to be a glimmer of hope, a very faint shadow of the old personality. Is the patient getting better? Will the old personality surface once again? Alas, no, this is just the disease's cruel way.

Health care professionals may try to comfort the patient's relatives by emphasizing that dementia is a common problem in old age, that they are not alone, and that many older people are similarly afflicted and are experiencing the same traumatic events. But what difference does this really make? Is it any consolation to know that almost half of the population over the age of 80 years may have dementia when one's own father or mother is no longer able to attend to even basic hygienic needs?

Statisticians study the prevalence of diseases among populations, and health care professionals attend to many patients who have dementia. But the relatives of a patient with dementia are only concerned about their loved one's condition. It is only that particular patient that matters, regardless of how many other patients are similarly afflicted. They sadly stand by as their loved one's memory, mind, and intellectual abilities fade from reality.

In one of life's ironic turns, the children are now placed in a reverse situation. They have to take care of the very person who took care of them when they were helpless and totally dependent. The important difference, however, is that when they were infants and helpless, it was only for a relatively short period--they were growing up and maturing. Soon they would be independent. With dementia, there is as yet no expectation of relief, no consistent long-lasting permanent improvement. Death is the only relief! To make matters worse, dementia is not usually a rapidly fatal disease; many patients survive for several years, sometimes as many as 20. What a terrible situation to be in! What an ordeal!

Health care professionals must be sensitive to the issues facing the relatives of patients with dementia. Unlike most other medical conditions, with dementia, the clinician's task does not end once the diagnosis is made, but essentially starts with the diagnosis. Health care professionals must be prepared for the long and often tumultuous relationship between the patient, the relatives, and themselves.

Modern changes in our society, such as increased population mobility and the change from the extended to the nuclear family, and regrettably to the single-parent family, add considerable burden to the care of patients with dementia. Rather than the load being distributed among several caregivers, it now tends to be concentrated in only a few-sometimes just one individual who also often has other responsibilities, such as caring for one or more children.

Furthermore, children who have moved away from the vicinity of their parents often interfere with the care of the patient. This frequency increases the level of stress of the siblings who live in the same town as the patient. Caretakers often do not recognize that their guilty feelings lead them to make unrealistic demands. It also is not uncommon for spouses or children to feel that they would be betraying their relatives by sending them to a nursing home.

There is, however, reason for optimism. Although there is as yet no cure for dementia, medications are available to slow down the rate of progress of the disease; in some instances, they even induce an improvement in the patient's cognitive functions. Researchers are working feverishly at finding safe and effective medications that can reverse Alzheimer's disease and the other dementing illnesses. Great progress already has been made. Indeed, an analogy can be made between Parkinson's disease and Alzheimer's disease. In both conditions, the basic problem is a reduced amount of neurotransmitters: dopamine in Parkinson's disease and acetylcholine and several other neurotransmitters in Alzheimer's disease. Parkinson's disease is now relatively easily treated, and there is no doubt that in the not too distant future, Alzheimer's disease also will join the ranks of treatable diseases. In the meantime, the clinicians' armamentarium to control a number of symptoms is increasing.

Directing caregivers to community organizations and support groups dedicated to the care of patients with dementia can alleviate some of the caretaker's burden. Fortunately, there are a number of community organizations that have much to offer patients and caregivers. Health care professionals attending to those with dementing illnesses should be able to direct the caregivers to such organizations.

This month's special feature is devoted to dementia. It is hoped that it will help clinicians provide better care for their patients.

Ronald C. Hamdy, MD, FRCP, FACP 

Editor