Understanding Dementia


By Dr. Raymond Zakhari

Dementia is one of the most common conditions that I deal with in my private practice. I wanted to provide a summary of the most common types of dementia. How to go about reducing the burden on the patient and loved ones. There are many kinds of dementia, but I am going to focus on 3 types.

Three Types of Dementia

The most common form of dementia is Alzheimer’s disease. Two other types of dementia include Vascular Dementia and Lewy Bodies Dementia. Distinguishing between types of dementia can be difficult. It can get easier to distinguish the type of dementia as the condition declines.

Five Phases of Worsening Decline

Dementia is a neurological disorder that ranges in severity. Here are 5 phases of progressive worsening decline:

  1. Mild Cognitive Impairment: the person thinks slower than usual or appears distracted. There can be some mild forgetfulness, and impaired problem-solving. Depression and anxiety can mirror these symptoms.
  2. Mild Decline. The symptoms of Mild Decline Dementia include:
    • increased confusion
    • impaired concentration
    • increased distractibility
    • trouble making plans or decisions and communicating desires
    • more frequent episodes of slowed thinking
    • more frequent episodes of forgetfulness

This stage can last several years.

  1. Moderate Decline. The symptoms include:
    • difficulty in getting dressed
    • neglect of hygiene
    • forgetting to eat
    • neglect taking medication
    • forget important appointments
    • lose key facts about personal life
    • bills go unpaid
    • the trash may not go out
    • they may wear the same clothes for a week or more
    • the dog may get overfed
    • there may be spoiling groceries in the refrigerator
  1. Severe Decline. Symptoms include:
    • needing a high level of care to the point of constant supervision
    • help in bathing/ changing
    • meal prep
    • using the bathroom

Other symptoms that may present in this stage include personality and behavior changes:

    • increased hostility
    • irritability
    • extreme flirtatiousness to the point of exhibitionism
    • emotional lability from laughing to crying for no reason

The brain at this point is at a very primitive stage of regression.

  1. The final stage before death is the Very Severe Decline. In this late stage of dementia, the person needs around-the-clock care. They will lose interest in eating and drinking. Or no longer feel thirst or hunger. They will speak less and appear more vacant. Eventually, they may stop communicating altogether.

The problem with dementia is the rate of decline can vary. Meaning it can be a gradual decline over months to years. Or it can accelerate the rate of decline seemingly out of the blue.

What are some symptoms to distinguish the types of dementia?

  • Vascular Dementia can have a characteristic step-wise declining process. Meaning a plateau followed by a steep drop-off in function as a result of a sharp increase in symptoms. Things will appear stable again, this will be the new lower functioning baseline. Then a steep drop again. This pattern is most common with vascular dementia. The problem is people can have more than one kind of dementia.
  • Alzheimer’s Dementia is the most common type. Frequently patients with this type have a vacant appearance. They become more forgetful and struggle to find the right words.
  • Lewy Bodies Dementia has many similar features to Alzheimer’s Dementia and Vascular Dementia. However, some distinguishing symptoms include a movement disorder that looks like Parkinson’s Disease. Patients may show the following symptoms:
    • shuffling gait
    • slow movement
    • hand tremors at rest
    • impaired physical balance and repeated falls
    • loss of coordination
    • smaller handwriting
    • reduced facial expressions
    • difficulty swallowing, increased drooling
    • weak voice
    • reduced eye blinking

In about 80% of cases, people with Lewy Bodies Dementia may also have visual hallucinations of little people. Unlike Alzheimer’s Dementia people with Lewy bodies may not have forgetfulness. They will show poor judgment, confusion about time and place, and also trouble with language and numbers.

People with dementia will often overestimate their abilities and be very resistant to help. The most common reason they end up in skilled nursing facilities is due to falling. Frequent trips to the emergency room lead to frequent hospital admissions. Frequent hospital admissions accelerate the decline.

What are the next steps?

  1. Get you or your loved one a comprehensive physical exam and psychiatric evaluation. The goal is to diagnose and treat any underlying conditions that can mimic symptoms of dementia such as a urinary tract infection, constipation, dehydration, depression, anxiety, or excessive medications.
  2. Consequently, make sure the goals of care are in place. In NY we have a form to help guide loved ones called the Medical Orders of Life Sustaining Treatment. The goal is to make a plan of care that you or your loved ones are aware of. This spells out whether one wants a natural death or every resource to save the patient. This ranges from feeding tubes to ventilators.
  3. Finally, your primary care provider can help you make these decisions. In some states, a Living Will can suffice. Furthermore, the best option is to appoint a healthcare proxy who knows your wishes and nuances and can make decisions for you should you not be able to decide.

How can I make them more comfortable?

Assuming the diagnosis of dementia is made stop telling the patient things like remember you used to like, or quizzing the patient as it is not helpful and often frustrating because they may be aware that they are losing their memory.

Tips, strategies, and advice for caregivers

One of the most helpful strategies in dealing with someone with dementia is distraction. Other strategies include enticing them with creature comforts such as favorite foods, music, scents, movies, and old photos. In this phase, do not take anything as a personal affront.

For instance, they may tell you how horrible you were as a child. How you’re abusing them and they never liked your bratty kids. They might say your father was a horrible lover.  They had an affair with his brother. Maybe you had a long-lost sibling.

The reason you cannot take these statements at face value is that they might not be real. They may mistake fantasy for reality.  These stories might come from someone else’s life, maybe even a TV show or movie. They could even combine all these scenarios.

How do I talk to my loved one with dementia?

  • Be gracious and give the answers, remind calmly, limit choices as they can be overwhelming, and remember to distract.
  • Establishing and maintaining a routine, and novelty can be disorienting and frustrating. Anticipate their needs.
  • Remain reassuring and calm as they can pick up your anxious energy, frustration, and irritability. Ensure their comfort from pain.
  • Make sure they are eating, drinking, urinating, and having consistent bowel movements at least once every 2 days.
  • Expressly make sure there is full frontal face-to-face communication of no more than 3 feet away and speak slowly. Make sure you have their attention.
  • Make everything simple to do and in small steps.
  • Agree, never argue.
  • Divert, do not try to use logic or reason (it is impaired).
  • Also, Distract, do not shame them.
  • Reassure, do not lecture.
  • Reminisce with them, but do not say remember (because they do not).
  • Simply repeat, do not say I told you already.
  • Do things they can do and avoid saying things like, “You cannot.”
  • Ask them, do not demand them.
  • Encourage, do not condescend.
  • Validate their feelings.
  • Above all, orient them frequently, “Hi Mom”, “Hi Dad”, “Frank”, or “Jill.” “It’s Monday morning.”  “The date is ____ and it’s time for breakfast.”

I hope you have found this post useful, please share it with someone who may find it useful.

Be sure to check out my podcast The Psychology of It All. It’s available on Anchor and also Apple Podcasts.

And make sure to read more of my blog posts where I cover a range of medical conditions.

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