Antidepressants Blog

Constipation is a very common problem in older people. Because so many people with dementia are old, many of them also suffer in this way. As mentioned in the section on incontinence, severe constipation can actually cause a form of faecal incontinence and if severe enough it can, strangely, sometimes lead to incontinence of urine as well. Many people only empty their bowels every three or four days and if this has been their normal routine, there is no point in trying to persuade them to empty their bowels more frequently. If, however, as for most people, this has been a daily routine, it doesn’t really matter if it becomes a little less frequent, such as every alternate day. This is particularly true if the person concerned is eating significantly less than he or she used to.

One of the best ways of keeping bowels functioning normally is to ensure that there is an adequate amount of roughage, or fibre in the diet. This helps the bowels to move the food along from one end of the alimentary tract to the other. A diet that is high in convenience foods, sweets, and cake is unlikely to contain an adequate amount of fibre. Wholemeal bread, cereals containing bran, and fresh fruit and vegetables are among the most palatable forms of fibre.

Some people have used purgatives all their lives and under these circumstances constipation can be very difficult to cure, adequate fibre intake on its own being insufficient to restore normal bowel function. If there is a problem, the doctor or the district nurse can usually assess its severity and recommend treatment.

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Just as loss of the sense of time with consequent repeated questioning can be very wearing, so can repeated questioning about other matters. It is often something that you can’t do anything about, as no matter how much reassurance you provide and no matter how many times you answer the questions, they will continue to be asked. It may result from just the memory loss but there is often a background of insecurity and the need for constant reassurance.

Sometimes writing down the answer to a complex question on a piece of paper or on a blackboard can be helpful, as the sufferer can then be diverted to the answer without the need for a lengthy explanation. More usually, however, the question is a simple one with a simple answer and writing things down just creates additional work and does little to help relieve the situation. Under these circumstances it is best to arrange to escape from time to time, to give yourself breathing-space. If you detect that the repetitive questioning is really a need for reassurance based upon a feeling of insecurity, perhaps provide feedback in the form of love and affection at times when it is not being sought and no questions are being asked. If the questioner’s needs are only fulfilled by getting a response to repeated questioning, this reinforces the pattern. If, however, the sufferer appreciates that he or she is loved and wanted and that this is true without having to seek attention, the questioning may occur less frequently.

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It has been mentioned already that there are similar abnormal changes in the brains of older people with Down’s syndrome and sufferers from Alzheimer’s disease. In addition to the structural changes there are also similar biochemical abnormalities. Whether or not older people with Down’s syndrome are particularly likely to develop dementia is, however, a matter of contention, as with so many other aspects of Alzheimer’s disease. In one study, less than half of the group of Down’s syndrome sufferers over the age of fifty demonstrated significant intellectual decline; in others, psychological impairments characteristic of Alzheimer’s have been found in the majority if not all.

Part of the problem lies in the fact that we don’t have adequate tests to measure dementia in people who have a pre-existing intellectual problem. The existing tests on previously normal people are difficult enough to interpret, so results for people with

Down’s syndrome can be very misleading. This is particularly true if all the Down’s syndrome subjects are studied only once and a judgement made as to whether, at say the age of fifty, they are suffering from a dementia-like illness. The best way of deciding whether or not dementia is an inevitable accompaniment to increasing age in Down’s syndrome is to undertake a longitudinal study. This means regular assessment over a period of time, providing an opportunity to compare change in intellectual ability over a number of years. Further research of this type is needed, but if it is confirmed that subjects with Down’s syndrome can exhibit the abnormal changes in the brain that occur in Alzheimer’s disease, yet do not all develop dementia or significant intellectual decline, then this would have important implications for the significance of the presence of senile plaques and neurofibrillary tangles, etc. in the diagnosis of Alzheimer’s disease.

The presence of plaques and tangles in the brains of people with Down’s syndrome stimulated examination of chromosome 2 I. The chromosomes are the structures on which all genes lie, and in Down’s syndrome there is extra chromosome 2 I material. At one time it was postulated that people with Alzheimer’s disease also had extra chromosome 2 I material. It was therefore possible to conjecture that an excess of genetic material on chromosome 2 I may cause the abnormalities in the brain in both Alzheimer’s disease and Down’s syndrome. This view appeared particularly attractive when it was discovered that the gene responsible for the formation of the substance in the centre of the senile plaque was also on chromosome 2 I. It seemed as if at least part of the cause of Alzheimer’s disease had been found. We now know that it is not as simple as this; although chromosome 2 I is implicated in the development of the senile plaque protein, it seems that the earlier hypothesis that this particular gene was the Alzheimer gene is unlikely to be true.

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This is the part of the brain that appears to bear the brunt of the disease process and in many ways it often seems as if it is the seat of the abnormal changes which eventually spread out from here to involve the other structures. The earliest symptom of Alzheimer’s disease is usually memory loss and it is the temporal lobe and in particular a special structure within it called the hippocampus that are particularly associated with memory.

Memory is often divided into two types, classified as short-term and long-term memory by most people working in this field. It may be more accurate to use a slightly different concept, that of recent and remote memory. In this discussion recent or short-term memory will be used to refer to memory processes relating to the preceding hours or days, occasionally a little longer, while long-term or remote memory can go back as far as childhood.

The way in which memory is affected in Alzheimer’s disease is, in trade union manner, ‘last in, first out’. A quite severely demented person, particularly with Alzheimer’s, can often remember in detail activities that happened in childhood while having forgotten what he or she had for lunch, even though that may have been only half an hour earlier. Some people use short-term memory to refer to the type of memory that only lasts a few seconds and this also is severely affected.

It would seem as if memory normally works by transferring information from very short-term memory processes to longer-term memory processes and the major defect in Alzheimer’s disease may be an inability to store any new information. Not only is it more difficult to put it into the long-term memory store, but once there it doesn’t seem to last as long as information that was put there years before.

The consequence of this memory problem is the familiar picture of a sufferer from Alzheimer’s disease being unable to grasp what is said to him or her, needing to have items repeated, needing to write lists, forgetting to keep appointments, and so on. This can often lead to hazards in the home and as the dementing process advances it is not uncommon for relatives to discover that saucepans are put on the stove and allowed to boil dry, or gas taps turned on but not lit.

An example of this kind of behaviour is the person suffering from Alzheimer’s disease who went shopping in a nearby town, having driven ten miles from the village in which he lived. After completing as many of the purchases as he could remember and having got into difficulty in working out the change, he then set out to find his car to make the return journey home. Unfortunately, he could not find his car anywhere, decided it had been stolen, and managed to walk all the way home, turning up several hours late, having caused much distress to his wife. This example illustrates two aspects of memory. On the one hand he was unable to remember where he had parked his car, which was in fact only about thirty seconds’ walk from the store in which he had done most of his shopping; on the other hand the long journey home was sufficiently familiar to enable him to arrive back safely, although rather late. When questioned he said that he hadn’t been able to telephone his wife as he couldn’t remember their telephone number and he hadn’t been able to take a bus because he couldn’t remember the name of the village in which he lived; being unfamiliar with the bus service, he was unable to ask someone which bus he should take.

The pattern of memory loss, particularly the differentiation between very short-term (lasting only a few seconds) and longer but still relatively recent memory function, changes as the disease progresses, with the very short-term memory traces becoming more disturbed as the disease advances, whereas early on in the condition it is memory loss over a period of a few minutes or so that is most marked.

Doctors often try to test memory by asking questions that test the subjects’ ability to place themselves in the correct environment — space or time. The former is particularly affected by the context in which the question is asked. For instance questioning an Alzheimer’s disease sufferer after he or she has been moved to a hospital, clinic, or ward will frequently reveal disorientation in space, while the same question asked of him or her at home may elicit the correct answer.

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Dementia probably afflicts in the region of a half to three-quarters of a million people in the UK. It is therefore a problem that already surpasses Aids in its magnitude and, unlike Aids, many of the causes of dementia, especially Alzheimer’s disease, are conditions for which there are no known preventative or therapeutic measures currently available. It is often estimated that approximately 7-10 per cent of the population aged sixty-five and over suffer from one of the dementias. This of course means that most people are not so afflicted and are, therefore, in a position to help those less fortunate than themselves. Clearly, those suffering from dementia are unable to improve their lot on their own, and cannot lobby for better facilities and care for themselves, or greater support for those looking after them. It is a great scandal that even in such a civilized society as ours, it is those who can make the biggest noise about their plight or who command a significant proportion of the vote, that are most likely to advance their position.

The size of the problem is going to escalate rapidly, especially in the next twenty years. Of those aged sixty-five to seventy, it appears that approximately one person in twenty has dementia, but the proportion of sufferers rises with increasing age, and of those over the age of seventy-five, one person in five will probably have some degree of dementia. The number of older people in our population is expected to increase greatly between now and the early years of the next century, and by far the largest proportional increase will be in those aged seventy-five and over. This means, of course, that the growing number of elderly people suffering with dementia is going to make greater and greater demands upon the rest of society, unless effective treatment or preventative measures become available in the near future.

Alzheimer’s disease is probably responsible for about 60 per cent, just a little under two-thirds, of all the cases of dementia. A further 15 to 20 per cent are probably caused by multiple infarct dementia and approximately another 15 per cent have both Alzheimer’s disease and multiple infarct dementia. This means that the other conditions, some of which are treatable, make up only a small proportion of the causes.

In approximately 10 per cent of people suffering from dementia up to the age of sixty-five, the underlying cause will be treatable. In older people, especially those over the age of seventy, this figure probably falls to 5 per cent, one person in twenty. This is nevertheless a significant and important number of people for whom treatment can alleviate an otherwise bleak future. Treatment of some of the underlying conditions will not necessarily reverse the dementia, but may only stop it from getting worse, but everybody who develops dementia should be screened for the underlying illness that is causing it as early as possible to limit the damage that is done before treatment is started.

Even for those in whom the dementia proves to be untreatable, once a diagnosis has been made it is easier to plan the future, advise relatives or other carers of what the future may hold and how they can best prepare themselves for what lies ahead. A lot of support is usually available, far more than is often realized, and access to this is facilitated once the diagnosis is known and accepted. In those parts of the country where sadly there is little support or none, knowledge of the diagnosis may allow relatives to get together to try to help each other and to lobby for more resources.

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