Understanding Dementia – Clinical Signs and Symptoms

Caregivers who work with older adults with dementia can benefit from understanding what toll the disease takes on a patient’s functioning. Earlier blogs have described many of the cognitive, behavioral and emotional changes that accompanying this dementing process. Today’s blog outlines the specific changes in mental ability that occurs, including the clinical signs of the disease.

Dementia is a syndrome or collection of symptoms that result in a global, or diffuse deterioration of intellectual abilities. It is important to recognize that the term dementia, in and of itself, does not say anything about the cause, or whether it is reversible. Of course, we are most familiar with primary degenerative dementias, which are caused by specific disease processes, such as Alzheimer’s disease, vascular conditions, Parkinson’s disease, and many others.

However, there are also secondary, or reversible (i.e., treatable) causes of dementia, including medications and dietary factors that can produce the same losses in intellectual functioning that we may see with a primary degenerative dementia. Pseudo-dementia (or false dementia) is the term for the dementia-like condition that is caused by severe depression. These treatable dementias are more common in community-dwelling elderly, especially those living alone, than in long term care settings, where treatable conditions have generally been ruled out.

One of the hallmarks of dementia is a loss of memory, especially memory for recent events (such as where an individual parked her car, or what she had for breakfast). More remote, or long term memory is generally intact. There is a loss of comprehension ability, which over time, limits how much the person understands what is being communicated. There is a loss of general information, that is, everyday facts and details that are commonly known by unimpaired individuals, such as the season, or major local or world events. We often see changes in attention and concentration ability, limiting the ability to stay on task for more than a few minutes. Judgment and common sense gradually decline with this condition, as do executive functions, such as reasoning ability and decision making.

There is a gradual loss of orientation, or what is also referred to as changes in sensorium. Cognitively-intact individuals are generally oriented in the temporal sphere (i.e., time), spatial sphere (i.e., place), and personal sphere (i.e., person). However, dementia results in a gradual loss of this orientation, first in the temporal, then spatial, and finally in the personal sphere. The remaining major cognitive changes we see in dementia are those related to verbal and language skills, first seen in word-finding difficulty and the ability to put ideas, thoughts, and needs into words. This progresses over time to severe deficits in the ability to communicate.

These changes occur insidiously, or cumulatively over time, and do not follow the same exact course for each individual affected. This makes it hard for caregivers to know what to expect, and how to adapt to the new losses in functioning. However, as we better understand these changes, and learn approaches that make up for or re-supply what is missing, there are fewer altercations and power struggles, and more time to focus on the individual’s residual strengths and capacities. These caregiving approaches will be discussed in coming weeks.

For more insights into these issues, see the CoHealth online programs on differentiating among depression, dementia, and delirium and on managing problem behaviors in dementia patients.  Useful, informative programs for families on facing Alzheimer's disease is also available on our website.  Visit the CoHealth website for more details about us, or mission, and our programs.

Principles of Behavior Management and Communication with Dementia – Principle No. 5

This is another post in a series about managing problem behaviors with older adults due to dementing illnesses, whether residing in nursing homes, assisted living facilities, or in their own homes. Because the person with dementia is gradually losing normal brain function and mental ability, caregivers need to adjust their caregiving approaches to avoid overwhelming the patient and, at the same time, not to overestimate what the patient can understand or accomplish.

One of the early changes occurring with dementia is the difficulty with language and self expression. Word finding difficulty is very common, and even though the person has an idea of what he is trying to say, he can’t put it into words. This is aphasia. It leaves the person frustrated and vulnerable to high distress if he cannot make his needs known, or express hunger, or pain, or need to use a toilet.  In terms of receptive language skills, the person with a dementing disorder can easily give the false impression that he fully comprehends words that are spoken by the caregiver. Though appearing as if he understands, in reality, there is little or no comprehension, thereby raising the caregiver’s frustration level, as well.

To compensate for these losses in language skills, keep communication as simple as possible, limited to short phrases and directions. Instead of a question like, “Would you like to come to the dining room and listen to some nice music, or would you rather sit outside in the nice sunshine?” Rather, “Would you like to listen to music or sit outside?” is a simpler question, and a simpler choice. If you have to repeat yourself, repeat the same words exactly to avoid confusion that comes with trying to process the first question, and now hearing a different one. Also, if the person is having trouble finding the right word, it is a good idea to supply the word, if you know it. Simple sentences, simple choices, reassurance, good eye contact, and patience help to keep the frustration level to a minimum.

There’s a useful saying that applies to care with the dementia patient:  pay now or pay later. Taking a little longer to understand a patient’s communications, even when rushed, prevents bigger problems later on when the behavior problems and distress escalate. Prevention is the key to behavior management. For more insights into these issues, see the CoHealth online courses on differentiating among depression, dementia, and delirium, improving quality of life in long term care, and on managing problem behaviors in dementia patients.