MENTAL HEALTH
Alzheimer’s and the will to choose
VARSHA DUTTA
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Dementia needs to be detected at an early stage and the diagnosis should be apt for that particular stage.
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“The person with dementia may lose all self awareness and with it, the sense of self identity. Enslaved in his own collapsing structure, a feeling of self does prevail which occasionally appears as lucid moments, where in figments he shows some semblance to his past. Now that the new self has emerged, there is a sense of preservation which shies away from the rest of the world… as if to survive, to shelter its being. A self though confined, yet comforting. A self that still is… ” By the author
“Human affairs are not serious but need to be taken seriously”. The medical community has taken itself too seriously by asserting that dementia is a disease, forgetting all along that the person still is. It is ironic under the given circumstances that Iris Murdoch had to be quoted. Iris, herself fell under the axes of this debilitating condition but never gave way to it.
Matter of concern
One of the pressing concerns in our community is the urgent need for an early and correct diagnosis of dementia. Pressing because this still is a disease at large and before we know it, wrecks so many lives. It is only after a correct diagnosis that we can choose to understand and experience a treatment choice specific to our needs.
The dementias epitomise memory and cognitive deficits. To receive a diagnosis, one must have deficits that are sufficiently severe to impair routine life. Pervasive among dementias are Alzheimer’s disease, dementia with Lewy bodies, and vascular dementia.
Alzheimer’s disease is neurodegenerative and marked by progressive cognitive decline and a gamut of brain pathology. There are variants of AD and the onset is often insidious Early detection of dementia is crucial. Along with a medical work up with laboratory and neuro-imaging investigations, a neuropsychological evaluation is imperative to know the dementia type, for planning the appropriate therapy. The neuropsychological examination involves tests sensitive to specific brain functions that determine its overall integrity while involved in a task.
It is often tricky telling dementias from one another, as their similarities conceal their enigmatic presentation. Often a case of severe depressive disorder is misdiagnosed as dementia and otherwise.
A patient (40) suffering from severe mood disturbances for one year also complained of memory impairments and difficulties with familiar tasks. Laboratory and neuro-imaging investigations were normal. Neuropsychological evaluation revealed a major depressive disorder. Her cognitive deficits coincided with the onset of depression that mimicked dementia.
Dementia often co-occurs with depression, which alone causes significant cognitive deficits difficult to distinguish from dementia. Cognitive deficits that occur with the onset of a depressive episode in context of previously normal cognitive functioning is due to depression. Neurologist Cummings opines that depression-related cognitive deficits can be a harbinger of dementia in older adults, which is why it is important to follow these individuals closely even after their depression remits.
Another patient (55) experienced mild memory deficits, like forgetting recent events and conversations and a weakening information processing speed, which was revealed during a working memory test, but the rest of his intellectual abilities were intact, with normal execution of daily life. Neuropsychological evaluation revealed Mild Cognitive Impairment (MCI). MCI occurs as memory complaints, with an isolated memory deficit, and relatively intact intellectual functions and activities of daily living. Approximately, 15 per cent of amnesic MCI will progress to Alzheimer’s disease within a year.
Look for signs
Dementia must also be distinguished from the slowdown in cognitive flexibility that occurs with aging. This is typically non-progressive and does not lead to functional impairment. Cognitive complaints are common in aging and may reflect depression. However, recent research suggests that some non-depressed older adults with significant memory complaints performing normally on neuropsychological tests, show mild changes in brain structure and activity similar to those with MCI or dementia. This is a warning that cognitive complaints in older adults with no dementia should be taken seriously, and these individuals should be followed closely to see if deficits emerge.
So far we have adhered to a largely medical approach towards dementia, ignoring the relevance of cognitive rehabilitation. The advent of anti-dementia drugs has helped achieve some therapeutic relief but does not obviate the need for a holistic approach. At present, there are no effective treatments to prevent or stop the insidious nerve cell death process once the disease begins.
Our treatment paradigm should focus on rehabilitation that is flexible and enhances psychosocial and cognitive responsibility by improving specific skills implicitly present in the person. Neuropsychology has made recent strides in the development of new cognitive techniques for treating Alzheimer’s disease. A number of studies have shown slower cognitive decline in AD patients who are mentally active.
Systemic cognitive rehabilitation can help people with mild Alzheimer’s disease, even in those not on medications, as shown by D. Lowenstein (Neuropsychologist) and group. The parts of the brain affected in Alzheimer’s disease make it hard to use standard rehabilitation procedures like the ones used in brain injuries, therefore rehabilitation should be modified as the disease progresses.
Studies so far have been on mild Alzheimer’s disease, and no research has yet indicated if rehabilitation would help people whose dementia has progressed beyond this stage. At present, any evidence of neural plasticity is contentious. While millions of dollars are spent every year on pharmacological trials that show partial benefits, it is critical for research to temper the possibility of cognitive and psychological augmentation, combining both drug and non-drug therapies.
We need to cognise that a self exists, though shielded from outward reality. It is only then that we can commit to person specific therapy which apart from enhancing self efficacy will also retain one’s will to meaning.
The writer is Clinical Neuropsychologist based in Bangalore. E-mail clinical.neuropsychologia@gmail.com
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